Pearson Ch36 Clinical Decision Making/Nursing Process/Nursing Plan of Care/Prioritizing Care

The nurse attended a program on a shared decision-making with other clients. Which statement by the nurse indicates effective learning? "I better be careful to use the correct medical terminology when appropriate." "I must communicate directly with the clients next of kin or designated decision-maker." "I may need to repeat the instructions a few times." "I will provide the instructions for multiple steps at a time."

"I may need to repeat the instructions a few times."

The nurse is discussing Benner's skill acquisition model. Which statement should the nurse include? (SATA) "A competent nurse usually has 2-3 years of experience." "Proficient nurses can see the whole picture." "An a advanced beginner is intentional in planning care." "New graduates are typically considered advanced beginners." "A novice acts by following rules."

"A competent nurse usually has 2-3 years of experience." "Proficient nurses can see the whole picture." "New graduates are typically considered advanced beginners. "A novice acts by following rules."

The nurse assesses a client further to determine which ordered PRN pain medication to administer. Which type of clinical decision making is the nurse using? choosing among alternatives intuition problem solving trial and air

Choosing among alternatives

The nurse is considering opposing views before making a decision. Which attribute of critical thinking is the nurse exhibiting? Open-mindedness fair-mindedness integrity Perseverance

Fair-mindedness

The nurse is using scenario-based simulations to teach the staff about clinical judgment. Which approach is the nurse using? Benner's skill acquisition model Maslow's hierarchy of needs Tanner's clinical judgement model Lasater's assessment rubric

Lasater's assessment rubric

which should be the nurses next action following the collection of assessment data? (SATA) measuring the data against standards to identify significant cues comparing the data with suspected medical problems clustering cues to generate tentative hypotheses analyzing the data for gaps and inconsistencies identifying strengths and resources

Measuring the data against standards to identify significant cues clustering cues to generate tentative hypotheses Analyzing the data for gapsand inconsistencies

The nurse is several clients who need care. Which type of decision does the nurse need to make? priority decision value decision scheduling decision Time management decision

Priority decision

A client is admitted to the emergency department with a rash on the trunk and extremities. The client reports difficulty​ breathing, chest​ tightness, and weakness. Respirations are 24​ breaths/min and​ even, pulse is 90​ beats/min and​ thready, and blood pressure is​ 96/70 mmHg. The client reports a recent history of a urinary tract infection and having been on sulfasalazine for the past 5 days. Which is the priority nursing assessment for this​ client? A. Peripheral edema B. Urine discoloration C. Gastrointestinal disturbances D. Airway patency

​D. Airway patency Rationale: Using the ABCs​ (airway, breathing, and​ circulation) to establish priority nursing​ interventions, the nurse would first establish airway patency based on the​ client's symptoms of difficulty breathing. This would take priority over assessment for​ edema, urine​ discoloration, and gastrointestinal disturbances.

The nurse is selecting a standardized plan of care for a client. Which should the nurse recall about the categorization of these​ plans? (Select all that​ apply.) A. Divided by sex of client B. Placed according to age groups C. Grouped according to client problems D. Alphabetized by standards of nursing care E. Filed by specialty problems

B. Placed according to age groups C. Grouped according to client problems E. Filed by specialty problems Rationale: Standardized plans of care are usually categorized by age​ group, client​ problems, and specialty problems. They are not categorized by the sex of the client or standards of care.

A homeless client presents to the emergency department​ (ED) complaining of severe chest pain. The client is well known to the​ ED, coming in frequently for various minor complaints. Which ethical principles should be most important for the nurse to​ consider? A. Privacy and confidentiality B. Accountability and responsibility C. Nonmaleficence and beneficence D. Justice and fairness

D. Justice and fairness Rationale: The principle of justice guides nurses in making decisions about setting priorities.​ Additionally, nurses must show fairness in treating individuals as equals. In this​ scenario, the nurse must treat the homeless client like any other client seeking care for chest pain.​ Accountability, responsibility,​ privacy, confidentiality,​ nonmaleficence, and beneficence are all important ethical considerations for the nurse but are not directly relevant to the situation.

A client presents with her third urinary tract infection​ (UTI) in the past several months. Which information is a priority for the nurse to obtain from the client to plan care related to the nursing diagnosis of ​Knowledge, Deficient​? A. Dietary practices B. Medications C. Family history D. Risk factors

D. Risk factors Rationale: Since the client has repeated urinary tract​ infections, the nurse would need to determine risk factors. Current​ medications, family​ history, and dietary practices do not relate to a diagnosis of ​Knowledge, Deficient. ​(NANDA-I ©2014)

The nurse is preparing a school-age child for surgery. Which intervention increases cooperation and decreases anxiety? using play therapy obtaining the childs assent for treatment having the child explore and operate the equipment when possible involving the parents to keep the child company while waiting

Having a child explore and operate the equipment when possible

The nurse caring for a client who has fallen blood pressure is trying to decide what action to take next which is the first step in making the decision? List the different options and their risks and benefits. Put the identified option into action. Select the best option to try in the situation. Identify the problem and decision to be made.

Identify the problem and decision to be made

The nurse knows that the baby is not sitting independently and recommends a developmental evaluation be performed. Which a attribute of critical thinking is the nurse using? salient cues inductive reasoning creativity Faulty reasoning

salient cues

The nurse is writing a plan of care for a client. Which criterion should the nurse include when writing nursing​ interventions? (Select all that​ apply.) A. Being realistic B. Ensuring relevancy to situation C. Including priorities of care D. Being specific and concise E. Being general and brief

A. Being realistic B. Ensuring relevancy to situation C. Including priorities of care D. Being specific and concise Rationale: Nursing interventions are dated and regularly reviewed for applicability toward goal achievement. Nursing interventions should be client​ centered; detailed,​ specific, and​ concise; realistic,​ relevant, and limited to the top three to five priority interventions for each nursing diagnosis.

The nurse is developing a mutually agreed upon goal with a client. Which purpose does this​ accomplish? A. Assist with identifying needs. B. Develop the​ nurse-client relationship. C. Obtain data in the assessment phase. D. Determine client problems.

B. Develop the​ nurse-client relationship. Rationale: When the client and nurse develop mutually agreed upon​ goals, this helps develop the​ nurse-client relationship. The nurse uses assessment to obtain data. Client problems are identified after assessment data is analyzed. Needs are identified in the planning phase.

A client presents to the emergency department​ (ED) complaining of pain and burning on urination. The client also tells the triage nurse that she noted blood in the urine the past few times she​ urinated, so she thought she should come to the emergency department. In which category should the nurse classify the​ client's problem to prioritize care in relation to other clients in the​ ED? A. Emergent B. Immediate C. Nonurgent D. Urgent

C. Nonurgent Rationale: Symptoms indicate that this client may be experiencing a urinary tract​ infection, which would be considered nonurgent since a delay in treatment would not result in a​ life-threatening situation. It would not meet the criteria for urgent or​ emergent/immediate.

The nurse has formulated a plan of care for a client. Which skill should the nurse use when implementing client​ care? (Select all that​ apply.) A. Physical examination B. Interpersonal C. Psychomotor D. Assessment E. Cognitive

B. Interpersonal C. Psychomotor E. Cognitive ​Rationale: The nurse uses three sets of skills when implementing client care. These skills are​ cognitive, interpersonal, and​ technical/psychomotor. Assessment is a type of cognitive or technical skill. Physical examination is a type of knowledge or technical skill.

When recommended for failing to label the date of changinga dressing the nurse states, "no one else on the unit does either." Which type of faulty reasoning is the nearest demonstrating? bandwagon Circular reasoning overgeneralization either-or fallacy

Bandwagon

The nurse working on a busy medical-surgical unit is caring for five clients. As the nurse is preparing to administer routine medications to the assigned​ clients, she is informed that a new admission will be arriving to the unit shortly. Which type of situation challenges the​ nurse's time management and organizational​ skills? A. Pitfall B. Emergent C. ​Pop-up D. Urgent

C. ​Pop-up Rationale: Events such as new admissions that are unexpected and require that nurses take time and attention away from their plan for the day are referred to as​ pop-ups. Pitfalls are unforeseen situations that harbor consequences for nurses and can result in client harm. Urgent and nonurgent events are methods of triaging and setting priorities for care.

The proficient nurse notices that unconscious client has a heart rate of 42 bpm. Which action should the nurse perform? review the clients med list and look for a potential side effects. notify the rapid response team document the findings and continue to monitor closely consult the policy and procedure book to determine which heart rate to notify the code team

Notify the rapid response team

A 15-year-old client tells the nurse that he wishes to make his own medical decisions. Which is the nurses best response? "you can sign the legal consent form if you prefer and make a medical decisions for your care." "you will need to provide a written consent for procedures in addition to your parents giving consent." "If you want to make your own healthcare decisions, you will need to consult an attorney." "your parents need to sign the consent form until you turn 18 years of age."

"If you want to make your own healthcare decisions, you will need to consult an attorney."

The nurse is creating a concept map for a client. In which order should the nurse complete the steps necessary to build this​ map? Number the steps in the correct order from first to last. Determine one appropriate goal for each nursing diagnosis cluster and add its shape to the side of the nursing diagnosis cluster. Gather and sort assessment data​ (subjective and​ objective) into significant clusters. Determine the priority nursing diagnosis that are relative to each of the clusters and place one nursing diagnosis with each of them. Evaluate whether the goal has been met, partially met or not met Place a shape with the​ client's initials,​ age, sex, and priority medical diagnosis in the middle of the paper. Develop a legend by assigning shapes and colors for nursing process phases and client information categories.

1) Develop a legend by assigning shapes and colors for nursing process phases and client information categories. 2) Put the shape with the pt's initials, age, gender, and priority medical diagnosis in the middle of the paper to illustrate the patient-centered nature of nursing care. 3) Gather and sort assessment data​ (subjective and​ objective) into significant clusters. 4) Determine the priority nursing diagnosis that are relative to each of the clusters and place one nursing diagnosis with each of them. 5) Determine one appropriate goal for each nursing diagnosis cluster and add its shape to the side of the nursing diagnosis cluster. 6) Evaluate whether the goal has been met, partially met or not met

Which information should the nurse include when writing an evaluation statement for a client admitted with a bowel​ obstruction? (Select all that​ apply.) A. A supporting statement about goal achievement B. A nursing statement about successful interventions C. A client statement about establishing new goals D. A conclusion statement about goal achievement E. Date and time that the evaluation was conducted

A. A supporting statement about goal achievement D. A conclusion statement about goal achievement E. Date and time that the evaluation was conducted ​Rationale: An evaluation statement contains the date and time that the evaluation was​ done; a conclusion statement about whether the goal was​ met, partially​ met, or not​ met; and a supporting statement giving the results of how the client did or did not achieve the goal. The evaluation statement does not contain a client statement about establishing new goals. This statement also does not contain a nursing statement about successful interventions.

The nurse working in a community clinic is reviewing the clients to be seen for the day. Which client should require more time in the​ schedule? A. A​ 75-year-old with recent cognitive decline B. A​ 32-year-old with newly diagnosed diabetes who is returning for a blood glucose recheck C. A​ 20-year-old who is being seen for evaluation of insulin pump management D. A​ 50-year-old who is being seen for blood pressure recheck

A. A​ 75-year-old with recent cognitive decline Rationale: An older client with cognitive issues may require more time than do other clients due to both developmental and cognitive issues. Blood pressure​ rechecks, insulin pump​ follow-up, and blood glucose rechecks of young and​ middle-aged adults would not necessarily require more time.

The nurse is developing a plan of care for a client admitted with congestive heart failure who has fluid overload. Which characteristic should be common to all​ goals? (Select all that​ apply.) A. Being relevant to the client B. Describing a single action C. Being identified for each nursing diagnosis D. Stating nursing actions E. Measuring nursing interventions

A. Being relevant to the client B. Describing a single action C. Being identified for each nursing diagnosis Rationale: Characteristics that are common to all goals include being identified for each nursing​ diagnosis, relevant to the​ client, and​ time-limited. Goals that are​ client-centered describe a​ single, specific action that the client will accomplish. Outcomes measure the effectiveness of nursing actions.

The nurse develops a nursing diagnosis of Self-Care Deficit related to the client's inability to perform activities of daily living(ADLs) due to left-sided weakness secondary to cerebrovascular accident. Which component of the nursing diagnosis wasnoted? (Select all that apply.) A. Diagnostic label B. Defining characteristics C. Etiology D. Data clusters E. Variations

A. Diagnostic label B. Defining characteristics C. Etiology

The nurse is​ collecting, analyzing, and synthesizing data. Which activity should be included as a step in this phase of the nursing​ process? (Select all that​ apply.) A. Documenting priority nursing diagnoses B. Selecting nursing strategies and or interventions C. Determining a​ client's problems D. Formulating diagnostic statements E. Determining a​ client's strength and risks

A. Documenting priority nursing diagnoses C. Determining a​ client's problems D. Formulating diagnostic statements E. Determining a​ client's strength and risks

The nurse is orienting a new nurse and teaching about plans of care. At which time should the nurse instruct the new nurse for evaluating the nursing​ care? (Select all that​ apply.) A. During a​ time-specified interval B. When discharging a client from nursing care C. During the implementation of an intervention D. Upon admission to the hospital E. At the end of a scheduled shift

A. During a​ time-specified interval B. When discharging a client from nursing care C. During the implementation of an intervention ​Rationale: Nursing care is evaluated during or immediately after an​ intervention, during​ time-specific intervals, and at discharge. Upon​ admission, the nurse is developing the plan of care to be used during the hospital stay. Nursing care may or may not be evaluated at the end of a scheduled shift. It will depend on whether an intervention was provided just prior to​ shift's end.

The nurse reviewed data collected on a client. Which reason should the nurse keep in mind for developing the plan of​ care? (Select all that​ apply.) A. Ensures continuity of care through communication for all involved in the​ client's care B. Ensures individualized​ client-centered care C. Serves as a comprehensive document that includes information for all client​ treatments, procedures, and medications D. Serves as a guide to assign nursing staff to care for each client E. Provides health insurance companies documented proof for reimbursement

A. Ensures continuity of care through communication for all involved in the​ client's care B. Ensures individualized​ client-centered care D. Serves as a guide to assign nursing staff to care for each client E. Provides health insurance companies documented proof for reimbursement ​Rationale: The purpose of nursing plans of care is to​ provide: (1) individualized​ client-centered care to meet the needs of the​ client, (2) a guide to assign nursing staff to care for each​ client, (3) health insurance companies documented proof for reimbursement for services rendered to the​ client, and​ (4) continuity of care through communication for all involved in the​ client's care.​ Additionally, nursing plans of care inform the nurse about specific observations or actions that need to be documented. The nursing plan of care is not a comprehensive document that lists all​ treatments, procedures, and medications.

The nurse is formulating a plan of care for a client who is diagnosed with cancer. Which factor related to client goals should the nurse​ consider? (Select all that​ apply.) A. Goals should be measurable. B. Goals should be attainable. C. Goals may address multiple actions. D. Goals should indicate whether treatment is successful. E. Goals should center on the client.

A. Goals should be measurable. B. Goals should be attainable. E. Goals should center on the client. ​Rationale: The client is always the subject of the goal and requires a​ specific, single action to ensure that all nurses understand what the client needs to do to achieve a goal. Goals should be​ measurable, attainable,​ relevant, and​ time-limited. An​ evaluation, not a goal​ statement, will indicate whether interventions were successful.

Which phrase should the nurse add to the​ intervention, "monitor intake and​ output" when using a standardized care plan for a client with congestive heart​ failure? A. Identify frequency B. Maximum allowed intake C. Minimum expected output D. A related goal

A. Identify frequency ​Rationale: Standardized care plans include interventions that may be​ open-ended. These interventions require that a frequency such as​ "monitor intake and output every two​ hours" is added. Goals or outcomes are already included in the standardized care plan. Minimum expected output​ and/or maximum allowed intake would not necessarily be added to an intervention but may be listed as​ goals/outcomes in the plan.

Which action by the nurse can help to avoid pitfalls that can result in client​ harm? (Select all that​ apply.) A. Incorporating client preferences as possible when prioritizing care B. Delegating care only when absolutely necessary C. Knowing client healthcare concerns D. Prioritizing client care appropriately E. Following ethical care practices

A. Incorporating client preferences as possible when prioritizing care C. Knowing client healthcare concerns D. Prioritizing client care appropriately E. Following ethical care practices Rationale: To avoid common pitfalls when providing​ care, the nurse should follow ethical care​ practices, know client healthcare​ concerns, prioritize care​ appropriately, and incorporate client preferences as possible when prioritizing client care. Appropriate delegation can be helpful to the nurse when prioritizing​ care, so it should not be avoided but used appropriately.

The nurse is teaching a patient to hold a pillow tightly against his abdominal incision when coughing. Which type of nursing intervention is the nurse​ practicing? A. Independent intervention B. Dependent intervention C. Collaborative intervention D. Supervised intervention

A. Independent intervention Supervised intervention Rationale: Teaching the client to use a pillow to splint the incision is an independent nursing intervention because the nurse does not need a prescription or supervision to implement the action. A collaborative intervention would be an action performed as part of an interdisciplinary team. Dependent nursing interventions are those that are initiated by the healthcare provider.

A new nurse creates a concept map for a complex client with multiple comorbidities and family​ issues; however, it is difficult to interpret. Which advice should the nurse provide to help enhance the ability to follow connections among the​ data? A. Keep the map​ simple; too many lines crossing each other make it difficult to follow data connections. B. Combine nursing interventions and goals into one shape for each to decrease the number of shapes on the map. C. Limit the number of assessment data clusters to no more than four or five clusters. D. Place evaluation of the goals and outcomes on a separate sheet of paper.

A. Keep the map​ simple; too many lines crossing each other make it difficult to follow data connections. Rationale: When building a concept​ map, it should be kept simple. If too many lines are​ created, it makes it difficult to follow the connections between the data. Concept maps should include all aspects of the nursing​ process; evaluation should not be placed on a separate sheet of paper. The number of assessment data clusters is determined by the​ data; the numbers of clusters should not be restricted. Goals and interventions should each have their own shape to help determine the relationships among all aspects of the concept map.

The nurse is planning to modify the plan of care for a client whose goals were not met. Which should be the​ nurse's first step before modifying the plan of​ care? A. Review each component of the plan of care. B. Determine the​ client's ability to follow the plan of care. C. Document the client is noncompliant with the plan of care. D. Discuss the care plan with the healthcare provider.

A. Review each component of the plan of care. ​Rationale: Before modifying an existing plan of care in which the goals were not​ met, the nurse should review each component of the plan to determine which aspects are not relevant. The nursing care plan and goals are set by the nurse and do not require healthcare provider intervention. There is no evidence the client is not adhering to the plan of​ care, and the nurse would have determined the​ client's ability to follow the plan prior to establishing the first set of goals.

A new graduate nurse is having difficulty prioritizing care and leaving the shift in a timely manner. The nurse manager notes that the new nurse rarely delegates tasks to the unlicensed assistive personnel​ (UAP) since a recent incident in which the new nurse delegated an inappropriate task to a UAP. Which action by the nurse manager should best help to address this​ situation? A. Reviewing state and facility guidelines concerning delegation with the nurse B. Having the UAP discuss with the nurse appropriate activities that he can do to assist the nurse with client care C. Reminding the nurse that she will quickly burn out if she does not delegate some care to the UAP D. Encouraging the nurse not to let the recent experience impact future actions

A. Reviewing state and facility guidelines concerning delegation with the nurse Rationale: To avoid pitfalls concerning delegation of​ activities, the nurse should be aware of state and facility guidelines.​ Thus, the best action of the nurse manager would be to discuss these guidelines with the new nurse. Encouraging the nurse not to let past experience guide future actions would not help the nurse to understand appropriate guidelines for delegation. Reminding the nurse that she will burn out quickly if she does not delegate tasks does not help the nurse learn to delegate tasks appropriately. Nurses should not rely solely on UAPs to indicate which tasks can appropriately be​ delegated; they should follow state and facility guidelines.

A​ 52-year-old male client with heart​ failure, renal​ failure, and diabetes has bilateral pedal edema. When creating the concept​ map, which information should the nurse place in the center of the​ map? (Select all that​ apply.) A. Sex B. Vital signs C. Medical diagnoses D. Report of pain E. Age F. Presence of edema

A. Sex C. Medical diagnoses E. Age ​Rationale: A shape with the​ client's age,​ sex, and medical diagnoses is placed in the middle of the map to illustrate the​ client-centered nature of nursing care. The​ client's initials are also included. Vital​ signs, complaints of​ pain, and the presence of edema are assessment data that the nurse will use to create data clusters.

A new nurse asks for help with clinical reasoning. Which suggestion should the nurse​ provide? A. Try using a concept map to create the nursing plan of care to enhance visualization of the relationships among clinical data. B. Spend time reviewing pathophysiology for each​ client's diagnosis and look for commonalities across them. C. Create a column plan of nursing care to better help distinguish each phase of the nursing​ process, which may help to clarify what is important. D. Review the nursing​ process, making sure to understand how each phase of the process contributes to a holistic view of the client.

A. Try using a concept map to create the nursing plan of care to enhance visualization of the relationships among clinical data. ​Rationale: Concept maps help nurses visualize and analyze relationships among clinical data to prioritize client​ needs, enhancing the ability to reason clinically. Spending time reviewing pathophysiology and reviewing the nursing process would not necessarily enhance the ability to reason clinically or analyze relationships. A column plan of care is not useful to analyze relationships between clinical data.

The nurse is revising the plan of care for a client who did not meet care goals. Which factor should the nurse​ consider? (Select all that​ apply.) A. Were the interventions that were selected​ appropriate? B. Did the client have access to planned​ interventions? C. Were interventions implemented as​ planned? D. What nurses were assigned to the​ client? E. Were the goals realistic and​ attainable?

A. Were the interventions that were selected​ appropriate? B. Did the client have access to planned​ interventions? C. Were interventions implemented as​ planned? E. Were the goals realistic and​ attainable? ​Rationale: When it is necessary to revise a plan of care because the client did not achieve one or more care​ goals, the nurse examines the reasons that the goals were unmet. These include whether or not the goals were realistic and​ attainable, whether the interventions that were selected were​ appropriate, and if the interventions were implemented as planned. The nurse also examines if there were any faulty assessment data. If a client did not have access to planned​ interventions, that would explain why interventions were not​ implemented, as well as suggest that assessment of the client was​ insufficient; a thorough assessment would have determined any limitations that the client had to accessing interventions. Which staff members were assigned to the client is not a consideration.

The nurse has assessed a client and determined the appropriate nursing diagnoses. Which activity should the nurse perform next​? ​(Select all that​ apply.) A. Write down the desired goals. B. Set priorities and goals in collaboration with the patient. C. Relate nursing actions to patient outcomes. D. Write priority nursing interventions. E. Reassess the patient to update the database.

A. Write down the desired goals. B. Set priorities and goals in collaboration with the patient. D. Write priority nursing interventions. Rationale: Once the assessment and diagnostic phases of the plan of care are​ completed, the nurse can perform the planning phase. This includes specifying patient​ goals/desired outcomes, and related priority nursing interventions. Reassessing the patient to update the database to keep it updated is a step for the implementation phase and relating nursing actions to patient outcomes is an activity for the evaluation phase. All other activities can be related to the planning phase.

Which statement should the nurse use to describe a​ four-column plan of care to a new​ nurse? A. ​"Assessment data is used to develop the​ plan, but it is not included as a column in the​ plan." B. ​"The four columns cover the first four phases of the nursing​ process; evaluation is done in the progress​ notes." C. ​"In a​ four-column plan, the goals and interventions are combined into one​ column." D. ​"Nursing diagnoses and assessment data share a column in this plan of care format.

A. ​"Assessment data is used to develop the​ plan, but it is not included as a column in the​ plan." ​Rationale: A​ four-column plan of care may include four​ columns: (1) nursing​ diagnoses, (2)​ goals/desired outcomes,​ (3) nursing​ interventions, and​ (4) evaluation. Nursing diagnoses and assessment data do not share a column in a​ four-column plan. Goals and interventions are not combined into one column in a​ four-column plan. Evaluation has a column in a​ four-column plan.

During a meeting to create a clinical pathway for​ stroke, the nurse is asked how the interventions for the pathway will be determined. Which response should the nurse​ make? A. ​"The interventions will be evidence​ based." B. ​"We will use interventions that have worked for other clients with a​ stroke." C. ​"Interventions will be​ suggested, and we will take a​ vote." D. ​"The director of neurology will determine the​ interventions."

A. ​"The interventions will be evidence​ based." ​Rationale: Clinical pathway interventions are evidence based. The clinical pathway is multidisciplinary to include healthcare​ providers, but the interventions are ultimately evidence based.​ Evidence-based interventions are well rooted in​ science, not just experience on past success or voting on popular interventions.

The nurse is evaluating the plan of care for a client admitted with acute pancreatitis. The nurse had formulated a nursing diagnosis of risk for fluid volume deficit. Which instance should the nurse document to mark the problem is​ resolved? A. A risk problem has been​ prevented, but the risk factors are still present. B. A potential problem has been​ prevented, and the risk factors no longer exist. C. The actual problem goals have been partially met. D. The actual problem goals have been​ met, but the problem still exists.

B. A potential problem has been​ prevented, and the risk factors no longer exist. ​Rationale: A potential problem can be documented as resolved if the problem has been prevented and the risk factors no longer exist. If the goals of an actual problem are partially​ met, the problem is not resolved. If the goals of an actual problem have been met but the problem still​ exists, the problem is not resolved. If a risk problem has been prevented but the risk factors are still​ present, the problem is not resolved.

A client with heart failure is having difficulty breathing and severe bilateral pitting edema of the ankles and feet. Which tool should the nurse expect to be prescribed to guide this​ client's care from the emergency department through discharge to​ home? A. Standardized care plan B. Clinical pathway algorithm C. Standards of care guidelines D. ​Client-specific clinical pathway

B. Clinical pathway algorithm ​Rationale: Clinical pathway algorithms can be used to guide multidisciplinary treatment across differing levels of severity of an illness. They include separate assessment and treatment progressive guidelines that can be used as the client transitions from the entry point to discharge. Standardized care plans provide guidelines for nursing interventions only. Standards of care define interventions for which nurses are held accountable and would not provide the guidance needed for this​ client's overall care.​ Client-specific pathways are given to clients to help them understand what to expect related to care.

The healthcare provider prescribes physical therapy to provide instructions on​ crutch-walking for a client. Which nursing intervention should the nurse include for the client after physical​ therapy? (Select all that​ apply.) A. Allow the client to walk the halls unassisted with crutches. B. Collaborate with physical therapy to determine progress. C. Instruct the client that​ crutch-walking will not be beneficial while in the hospital. D. Assist the client with​ crutch-walking. E. Measure the​ client's height to ensure crutches fit.

B. Collaborate with physical therapy to determine progress. D. Assist the client with​ crutch-walking. ​Rationale: When working collaboratively with the physical​ therapist, the nurse should​ follow-through with interventions provided in therapy.​ Therefore, the nurse should assist the client with​ crutch-walking and collaborate with the physical therapist to determine progress towards goals. The nurse should supervise the client when ambulating the halls with crutches as this can lead to falls. The nurse should not instruct the client that​ crutch-walking is not beneficial in the hospital as the plan set by physical therapy should be followed to meet goals. The physical therapist will ensure the crutches are set at the appropriate height.

A healthcare organization is adopting the use of a​ three-column nursing plan of care. Which information should be documented in these​ columns? (Select all that​ apply.) A. Evaluation B. Nursing diagnoses C. ​Goals/desired outcomes D. Nursing interventions E. Assessment

B. Nursing diagnoses C. ​Goals/desired outcomes D. Nursing interventions ​Rationale: This type of plan of care identifies a column for data that corresponds to each phase of the nursing process. For a​ three-column plan, the columns are nursing​ diagnosis, goals/desired​ outcomes, and nursing interventions. Evaluation is a part of a​ four- or​ five-column plan. Assessment is a part of a​ five-column plan.

The nurse is developing a plan of care for a client hospitalized for an acute exacerbation of Crohn disease. Which collaborative action should the nurse include to support the care of this client while​ hospitalized? A. Weigh daily. B. Obtain a dietary consult. C. Review factors that aggravate or alleviate pain. D. Encourage verbalization of feelings related to the diagnosis.

B. Obtain a dietary consult. Rationale: When providing care for clients it is important to include collaborative activities in the plan such as asking a dietician to consult with the client. Weighing the client​ daily, reviewing factors that aggravate or alleviate​ pain, and encouraging verbalization of feelings would not be collaborative activities because the nurse would do those independently.

The nurse is developing a plan of care for a client with an acute myocardial infraction​ (MI). Which intervention should the nurse include in the plan to address preventive and health maintenance aspects of the​ client's care? A. Reviewing the client history for previous​ angina, anginal​ equivalent, or MI pain B. Teaching about​ heart-healthy living prior to discharge C. Encouraging position changes every 2 hours to help keep fluid from pooling in the bases of the lungs D. Assessing skin temperature and peripheral pulses every 2dash-4 hours to monitor tissue perfusion

B. Teaching about​ heart-healthy living prior to discharge Rationale: Nursing plans of care should include preventive or health maintenance aspects in addition to restorative aspects. Including teaching about​ heart-healthy living would focus on prevention. Reviewing client​ history, assessing skin temperature and pulses every 2dash-4 ​hours, and encouraging position changes every 2 hours focus on restoration.

The nurse participating on a clinical pathway committee reviews the goals of the committee. Which clinical pathway development goal should the nurse suggest​ revising? A. The committee will develop each clinical pathway based on the​ diagnostic-related grouping​ (DRG) expected length of stay. B. The committee will develop clinical pathways for complex conditions impacting clients with the highest risk of mortality. C. The committee will review the latest published evidence for each clinical pathway disease. D. The committee will be comprised of healthcare​ providers, nurses,​ therapists, dieticians, case​ managers, and pharmacists.

B. The committee will develop clinical pathways for complex conditions impacting clients with the highest risk of mortality. Rationale: Clinical pathways are plans of care for predictable health​ conditions, not​ complex, high-mortality care. Clinical pathways reflect daily activities and goals for the number of days a DRG sets as expected length of stay for that condition. Clinical pathways are evidence based and involve the multidisciplinary team.

A client scheduled for cesarean birth is anxious and asks about the surgery. Which should the nurse include when providing the client with a​ client-specific pathway? A. ​"These are the guidelines we will be using as we care for​ you, it tells you day by day what each healthcare team member will be​ doing." B. ​"This gives you information about​ activities, diet,​ medications, treatments, and tests you can expect from now until you​ deliver." C. ​"Since most of your care will be provided by​ nurses, this will tell you about the common things we see with cesarean deliveries and what kinds of things we will be doing for​ you." D. ​"This gives you a visual image of what to expect while you are here. You can easily see how things will be done from now until you go home with your​ baby."

B. ​"This gives you information about​ activities, diet,​ medications, treatments, and tests you can expect from now until you​ deliver." ​Rationale: Client-specific pathways are given to clients to help them understand what to expect related to care and can include information about​ activities, diet,​ medications, and so on. Clinical pathways include a​ day-by-day listing of interventions to be carried out and outcomes to be achieved. Nurses often use concept maps to help visualize and analyze relationships among clinical data to prioritize client needs. A standardized care plan guides nursing care activities for specific diagnoses.

The nurse is tasked with purchasing a few items that would help preschoolers in the healthcare environment. Which items should the nurse consider purchasing? both male and female dolls handheld video games coloring books and crayons building blocks

Both male and female dolls

The medical-surgical nurse is planning the day immediately after receiving report. Which should be the primary nursing intervention when prioritizing​ care? A. Ascertaining interventions B. Analyzing collected data C. Assessing client situations D. Assigning staff to clients

C. Assessing client situations Rationale: The first step when prioritizing care is assessment. Assessment is the process of gathering information to make decisions. Assessment includes knowing individual​ clients' health statuses to prepare for anticipated or unanticipated changes. Ascertaining interventions would occur after the assessment. Analyzing collected data would occur after an assessment. Assigning staff to clients would occur after knowing the number and level of caregivers available to provide care.

The nurse is creating a concept map for an assigned client. Which activity should the nurse perform that forms the basis of the map to determine priority nursing​ diagnoses? A. Creating a legend for the concept map by assigning shapes and colors for each phase of the nursing process and other categories of client information B. Placing client baseline information and medical diagnoses in the center of the concept map C. Clustering objective and subjective nursing data and placing each piece of significant data on one assessment shape D. Drawing connecting lines from clustered assessment data to the relevant nursing diagnoses

C. Clustering objective and subjective nursing data and placing each piece of significant data on one assessment shape Rationale: To determine priority nursing​ diagnoses, the nurse must cluster objective and subjective nursing data and place each piece of significant data on one assessment shape. Once priority nursing diagnoses are​ created, the connecting lines will be drawn. Client baseline information is placed in the center of the map to indicate the​ client-centered nature of concept maps. Creating a legend for a concept map is the first step and helps to identify what various aspects of the concept map mean.

The nurse reviews the clinical pathway for a client recovering from a colon resection. In which way should the nurse use this pathway to support the​ client's care?​ (Select all that​ apply.) A. List detailed nursing activities to support client recovery and care. B. Include interventions to treat complications secondary to the procedure. C. Identify treatments to be performed by different types of healthcare providers. D. Customize to meet the​ client's specific needs. E. List​ day-by-day interventions to be carried out and outcomes that should be achieved.

C. Identify treatments to be performed by different types of healthcare providers. D. Customize to meet the​ client's specific needs. E. List​ day-by-day interventions to be carried out and outcomes that should be achieved. Rationale: Clinical pathways are standardized multidisciplinary plans that outline care required for clients with​ common, predictable health conditions. They can be customized to meet each​ client's specific needs​ (while keeping the guidelines in​ mind). They include treatments to be performed by different types of healthcare providers and include a​ day-by-day listing of interventions to be carried out and outcomes to be achieved. They do not include detailed nursing activities or interventions. They may include activities to prevent complications but not activities to address complications because complications would not be an expected outcome for this​ common, predictable health condition.

The nurse on a surgical unit has evaluated that client outcomes per the nursing care plan have not been met. Which action should the nurse​ take? A. Confront the client on missing target goals. B. Abandon the care plan. C. Reassess and revise the care plan. D. Immediately call the healthcare provider.

C. Reassess and revise the care plan. Rationale: Nursing plans of care are created and implemented by nursing. If goals are not​ met, the nurse reassesses and revises the plan of​ care; the nurse does not abandon the plan of care. The healthcare provider does not need to be urgently notified of nursing care plan goal​ changes, nor is the client confronted in a hostile manner. Mutual goal setting and communication with the client will support meeting care goals.

Which statement by a nurse unfamiliar with standardized nursing plans of care should the nurse manager​ correct? A. ​"This standardized plan is useful for​ common, predictable​ problems, but I will need to create an individual plan for unique client​ needs." B. ​"I need to complete the client assessment before I can select the appropriate standardized plan of​ care." C. ​"These standardized care plans are​ great; I​ don't have to spend time individualizing a​ plan." D. ​"This standardized plan specifies the nursing​ care; it is not intended to guide care for the other involved healthcare​ disciplines."

C. ​"These standardized care plans are​ great; I​ don't have to spend time individualizing a​ plan." ​"This standardized plan specifies the nursing​ care; it is not intended to guide care for the other involved healthcare​ disciplines." ​Rationale: A standardized nursing plan of care must be individualized to fit the unique needs of each individual client. Client assessments are used to guide the selection of the appropriate standardized plan. Standardized plans specify nursing​ care; while other disciplines may review it to determine what nursing care is​ planned, it does not provide guidance for other disciplines. Standardized plans are useful for​ common, predictable problems.

The staff development trainer is preparing information for new nursing employees. Which statement should the trainer use to describe a feature of a standardized care​ plan? A. Client care is identified in sequence for each day during the projected length of stay. B. Care is planned by entering data into columns that correspond to the nursing process. C. A plan of care is developed using colored shapes of various sizes. D. A plan of care is selected and then individualized to meet a​ client's needs.

D. A plan of care is selected and then individualized to meet a​ client's needs. Rationale: A standardized care plan is a prepared plan of care. After completing the​ assessment, the nurse selects the standardized care plan appropriate for the client and then individualizes it to meet the​ client's needs. Entering data into columns that correspond with the nursing process describes a column plan of care. Pictorially describing client problems and care needs with colored shapes of various sizes describes a concept map. Identifying client care in sequence for each day during the projected length of stay describes a clinical pathway.

The nurse is working with an adult client with a diagnosis of posttraumatic stress disorder​ (PTSD). The client shares that he has begun exercising daily at a local​ gym, which lowers his daily stress level. Which type of nursing diagnosis would best capture the​ client's exercise​ behavior? A. Syndrome diagnosis B. Wellness diagnosis C. Risk diagnosis D. Health promotion diagnosis

D. Health promotion diagnosis

An older​ client, who also suffers from who has partial memory loss and anxiety is scheduled for a major surgical procedure in two weeks. Which information should the nurse consider providing to the client about the​ surgery? A. Wait until the day of surgery to explain the procedure to the client to decrease anxiety. B. Provide pamphlets for the client to read and review about the procedure. C. Provide a detailed description of the upcoming surgery. D. Present and discuss the surgery in simple terms.

D. Present and discuss the surgery in simple terms. ​Rationale: Memory impairment in older clients can make it difficult for the client to assist in planning care.​ Therefore, the nurse should present and discuss the upcoming surgery in simple terms. The nurse may need to repeat the information​ frequently, but this should be presented in words the client can understand. The nurse should not wait until the day of the surgery to present the information as this will increase anxiety and not allow the client to be involved in care. Pamphlets may be difficult for the client with cognitive impairment to follow.

The nurse prioritizes care for a client with diabetes mellitus using​ Maslow's hierarchy of needs. Which need is identified as the priority for this​ client? A. The nurse teaches the client proper home safety techniques to prevent diabetic wounds. B. The client joins the local American Diabetes Association support group. C. The client attends classes to deal with body image after amputation of the right leg. D. The nurse teaches the client how to properly change dressings on the​ right-leg amputation site.

D. The nurse teaches the client how to properly change dressings on the​ right-leg amputation site. Rationale: When prioritizing care based on​ Maslow's hierarchy of​ needs, physiological needs will come before​ safety, social, and esteem needs. Caring for an amputation site is meeting a physiological need. Attending a class to deal with​ body-image issues addresses an esteem need. Teaching the client about safety techniques to prevent diabetic wounds addresses a safety need. Joining a support group meets an esteem need.

The nurse is discussing the role of intellect and critical thinking. Which benefit should the nurse include? (SATA) Approaches situations objectively Differentiates fact from opinion Helps to clarify concepts Assists with evaluating performance Helps the nurse think outside the box

approaches situations objectively differentiates fact from opinion Helps to clarify concepts

The nurse is an advanced beginner within Benner's skill acquisition model of clinical judgement. Which characteristic describes the nurse? (SATA) begins to recognize cues is able to intentionally plan care follow rules when acting is a new graduate can see the whole picture

begin to recognize cues is a new graduate

The nurse is planning care for a client with unstable blood glucose levels. Which should be the first action by the nurse? Carry out solutions to manage the problem establish a specific nursing diagnosis complete an assessment on a client Create a plan of nursing care for the client

complete an assessment on a client

The nurse is caring for a pregnant client who wants a healthcare provider to let her make all the decisions. Which decision making model is the client looking for? mutualistic holistic consumerist paternalistic

consumerist

The nurse uses a clinical decision tree to determine the best course of action for a client who has signs and symptoms of a myocardio infarction. Which statement is true regarding this clinical decision tool? (SATA) It can assist and decision making. it requires higher level decision-making. it cannot be implemented by all nurses. it requires no decision making. it requires standardization of care.

it can assist in decision making it requires standardization of care

The nurse is explaining Tanner's clinical judgment model to a student nurse. Which element should the nurse explain is needed first make a clinical judgment? intuition initation of practice learning in nursing school multiple years of experience

learning in nursing school

The nurse is teaching a new nurse about developing an appropriate nursing diagnosis for a client. Which information should the nurse use to accurately describe nursing​ diagnosis? (Select all that​ apply.) A. Nursing diagnosis describes responses to a health problem. B. A nursing diagnosis is a judgment statement. C. Nursing diagnosis is flexible and changes based on client responses. D. Nursing diagnosis is uniform between clients. E. A nursing diagnosis is a condition that nurses are licensed to treat.

nursing diagnosis describes responses to a health problem A nursing diagnosis is a condition the nurses are licensed to treat nursing diagnosis is flexible and changes based on client responses A nursing diagnosis is a judgment statement

The nurse states, "chronic obstructive pulmonary disease is a chronic pulmonary disease and the nurse should place the client and high Fowlers position." Which clinical reasoning concept is the nurse using in the statement? (SATA) inquiry inference opinion fact Judgment

opinion Fact

The nurse is organizing care for the day for the assigned clients. Which client should the nurse give highest prioritization to ensure appropriate medication​ administration? A. A client receiving several intravenous​ antibiotics, each to be infused over 30-60 minutes B. A client who is receiving daily dialysis C. A client with diabetes requiring insulin coverage QID D. A client with unstable vital signs receiving multiple blood pressure medications

​A. A client receiving several intravenous​ antibiotics, each to be infused over 30-60 minutes Rationale: When the nurse is caring for multiple​ clients, setting of priorities is determined by the significance of the interventions for the clients. In this​ situation, the client receiving several intravenous​ antibiotics, each of which need to be infused over a specific time​ frame, would need to be prioritized to ensure adequate medication administration. QID insulin​ coverage, regularly scheduled blood pressure​ medications, and daily scheduled dialysis would not have higher prioritization than would the client receiving multiple intravenous antibiotics that must be administered in the correct order over the appropriate time frame.

The nurse is prioritizing client care as​ low, medium, or high priority for the current assignment. Which client should the nurse identify as having a ​high-priority​ circumstance? (Select all that​ apply.) A. A client who is receiving warfarin​ (Coumadin) B. A client with congestive heart failure and shortness of breath C. A client who is experiencing extreme bouts of diarrhea D. An extremely confused older client E. A client with emphysema and a pulse oximeter reading of 88

​A. A client who is receiving warfarin​ (Coumadin) B. A client with congestive heart failure and shortness of breath E. A client with emphysema and a pulse oximeter reading of 88 Rationale: High-priority circumstances include clients with a risk for​ bleeding, such as a client receiving warfarin​ (Coumadin), clients with ineffective breathing​ patterns, and clients with impaired gas exchange. A confused client and a client with diarrhea would have​ medium-priority circumstances.

The nurse in an emergency department​ (ED) shares with a fellow nurse​ that, due to the busy pace of the​ day, he has not even been able to go to the bathroom since he arrived for his shift 6 hours ago. Which response by the fellow nurse should best address this​ situation? A. Offering to oversee the​ nurse's clients so that a​ 15-minute break can be taken B. Encouraging the nurse to let the supervisor know so that appropriate actions can be taken C. Discussing better ways to prioritize and manage time with the nurse so that in the future he will be able to take needed breaks D. Listening to the​ nurse's concerns and offering verbal encouragement to make it through the rest of the shift

​A. Offering to oversee the​ nurse's clients so that a​ 15-minute break can be taken Rationale: It is important that nurses take quick​ 15-minute breaks to​ refresh, reenergize, and take care of bodily​ functions, so the best response by the fellow nurse would be to cover for the nurse to allow this break to occur. Encouraging the nurse to let the supervisor​ know, listening to the​ nurse's concerns, and discussing better ways to manage time and prioritize would not provide the​ much-needed break for the nurse.

The home care nurse is planning the order of clients for the day. Which client should the nurse prioritize as needing to be seen first​? A. A client with daily dressing​ change, normally done at 0800 per client preference B. A newly diagnosed diabetic client who is administering morning insulin independently for the first time C. A client requiring indwelling catheter change due to leakage D. A client being seen poststroke for rehabilitation and education about poststroke care

​B. A newly diagnosed diabetic client who is administering morning insulin independently for the first time Rationale: A newly diagnosed client who is administering insulin independently for the first time creates a time constraint. The nurse would see this client first to ensure that the insulin is being administered properly. While client preferences are an important​ consideration, the time constraint of the insulin would be a higher priority. A client being seen poststroke for rehabilitation and education as well as a client with a leaking indwelling catheter would also be lower priorities when planning the order of clients for the day.

The nurse is providing care for several clients with neurologic dysfunction. Which client should be placed closest to the​ nurses' station? A. A​ 72-year-old client who is 2 days postoperative for a carotid endarterectomy B. A preoperative​ 68-year-old client who was diagnosed with an astrocytoma C. A newly admitted​ 65-year-old client who experienced an acute subdural hematoma D. An​ 80-year-old client with viral meningitis who was admitted 3 days ago

​C. A newly admitted​ 65-year-old client who experienced an acute subdural hematoma Rationale: When prioritizing​ care, the nurse needs to consider all relevant factors. A newly admitted client with a recent subdural hematoma would be considered a high priority due to risk for​ seizures, stroke, brain​ herniation, and so forth and should be placed closest to the​ nurses' station. A client 3 days​ postmeningitis, a preoperative​ client, and a client who is 2 days postoperative for a carotid endarterectomy would have more stability and less priority than a newly admitted client with a subdural hematoma.

The nurse caring for a client with diabetes mellitus receives a report from another nurse that the client is experiencing a hypoglycemic episode. The nurse immediately prepares to administer 50 mL of D50 IVP. Upon entering the​ room, the nurse notes that the client seems alert and does not have any current complaints and decides not to administer the D50. Which pitfall was avoided by the nurse in this​ situation? A. Incomplete assessment B. Failure to do periodic assessments C. Relying solely on​ another's assessment D. Poor time management

​C. Relying solely on​ another's assessment Rationale: In this​ situation, the nurse prepared to administer D50 IVP based on the other​ nurse's assessment. Using this information to set priorities could have resulted in a negative client outcome. The potential pitfall in this situation was not created by an incomplete​ assessment, poor time​ management, or failure to do periodic assessments.

Which client should the nurse assess first after receiving the​ change-of-shift report? A. A client with a bowel obstruction who is complaining of nausea B. A client with type 1 diabetes mellitus with blood glucose of 82​ mg/dL C. A client with hypertension with a blood pressure of​ 168/88 mmHg D. A client with heart failure who is complaining of shortness of breath

​D. A client with heart failure who is complaining of shortness of breath Rationale: Using the ABCs​ (airway, breathing, and​ circulation) as a​ guide, the nurse should first assess the client with shortness of breath. This would take priority over a client complaining of​ nausea, a client with an elevated​ (but not critically​ elevated) blood​ pressure, and a client with a normal blood glucose reading.

The nurse administered blood pressure medications to the wrong client. Upon realizing the​ error, the nurse notes that the last blood pressure assessment of the client who received the wrong medication was​ 82/50 mmHg. Which level of urgency would be required to address this​ situation? A. Nonacute B. Acute C. Imminent death D. Critical

​D. Critical Rationale: In this​ situation, a blood pressure medication was administered to the wrong client who has low blood​ pressure, creating a critical situation to which the nurse needs to respond quickly since the​ client's condition could become life threatening. This would not be an acute or nonacute​ situation, as it is a​ medium-high priority. It is not likely that this error would result in death of the​ client, so the choice of imminent death would not be appropriate.

The nurse is planning the day on a general medical unit. Which activity should the nurse prioritize as​ "must do" and not advisable to be delegated to unlicensed assistive personnel​ (UAP)? A. Assisting clients with hygienic care activities B. Ambulating a stable client to the bathroom C. Collecting vital signs on assigned clients D. Health teaching for a client being discharged poststroke

​D. Health teaching for a client being discharged poststroke Rationale: "Must​ do" activities carry the highest priority for completion and should not be delegated. Health teaching and discharge teaching must be done by the nurse. Collecting vital​ signs, ambulating a stable client to the​ bathroom, and assisting clients with hygienic activities can all be safely delegated to unlicensed assistive personnel​ (UAPs).

Which action should the nurse take to best involve hospitalized clients in their care and avoid pitfalls related to not involving clients in their own​ care? A. Orienting the client and family to the hospital facility and routines B. Informing clients of the daily schedule of care C. Asking the​ client's family about usual patterns of behavior D. Observing client behaviors for cues about preferences

​D. Observing client behaviors for cues about preferences Rationale: To avoid pitfalls related to not involving clients in their own​ care, the nurse should observe client behaviors for cues about preferences. Informing clients about the daily schedule of care and orienting clients and families to the hospital routine do not provide information about client preferences. While a family may be able to provide information concerning client​ preferences, it is best to ask or observe the client to determine preferences.

The nurse is assessing a​ client's peripheral circulation after cardiac catheterization. Which finding is the highest​ priority? A. Pulses are palpable and bounding. B. The femoral site is soft and free of hematoma or bleeding. C. The​ client's toes are warm and pink. D. The client is experiencing numbness in the toes.

​D. The client is experiencing numbness in the toes. Rationale: After cardiac​ catheterization, a finding that the client is experiencing numbness may indicate a complication of the​ procedure, thus it would be the highest priority. Warm and pink​ toes, palpable, bounding​ pulses, and a femoral site free of hematoma and bleeding are all normal findings.