Session 1 Seminar Assignment

Which question or statement would be an appropriate termination of the health history interview?

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

A nurse manager is talking with a new nurse. The nurse manager determines that the new nurse is thinking critically based on which statement?

"If I give this medication, the client will probably be sleepy"

The client is an older adult with osteoporosis. The client fractured a hip following a fall and had surgery. The nurse identified interventions based on the client's needs and outcomes. Which actions are nurse-initiated interventions?

- Assess vital signs and oxygen saturation every 4 hours - Instruct the client about foods high in calcium - Assess surgical wound daily for redness, inflammation, and drainage

Which actions should the nurse perform during the planning step of the nursing process?

- Establishing priorities - Identifying expected client outcomes - Selecting evidence-based nursing interventions - Communicating the plan of nursing care

Which components must be included in an outcome?

- The action the client will perform - The particular circumstances in which the outcome is to be achieved - The client or some part of the client - A target time by which the client is expected to be able to achieve the outcome

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89L). The nurse raises the head of the bed and applies oxygen at 3L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions?

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

Which provides the nurse with the MOST reliable basis on which to formulate a nursing diagnosis?

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

The client demonstrates stair climbing using a quad cane. This is an example of:

A psychomotor outcome

Which is a health care provider-initiated intervention?

Administer oxygen at 4 L/min per nasal cannula

A nurse develops the nursing diagnosis "appendicitis" and "acute pain" for a client. Which of the diagnosis is a medical diagnosis?

Appendicitis

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 the nurse evaluate this outcome?

Ask the client to demonstrate self-injection of insulin

A client comes to the emergency department reporting severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating?

Assessing

The correct progression of steps of the nursing process is:

Assessment, diagnosis, planning, implementation, and evaluation

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?

Client no longer requires supplemental oxygen

Which group of terms BEST describes the nursing process?

Client-centered, systematic, outcome-oriented

Which nursing assessment guideline is most accurate?

Collect assessment data about the client continuously

The nurse takes a client's vital signs and finds the pulse rate to be 120 bpm. What would the nurse do next to interpret and analyze this pulse rate?

Compare the client's pulse rate to the standard range

What is the BEST way for a nurse to obtain a full set of data when performing an assessment of a client?

Complete a systematic nursing history and nursing examination

Which statement regarding the difference between data collected for assessments and data collected for evaluation is correct?

Data collected for assessment identify client health issues, whereas data collected for evaluation determines whether client outcomes are being achieved

How should the nurse ensure that care is not legally negligent?

Documenting the nursing actions in the client's record

After the nursing plan of care has been developed, the nurse knows that:

Each encounter with the client is an opportunity to reassess and revise the plan of care, is neccessary

The nurse is caring for a client who is postoperative and has pain that is an 8 on a scale of 0 to 10. There is an order for intravenous pain medication every 4 hours as needed. The nurse administers the prescribed pain medication to the client. What should the nurse do to assist in meeting this client's desired outcome of a pain scale score less than 4 on a scale of 0 to 10?

Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect

The nurse is caring for a client who is experiencing an asthma attack. 10 minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client is breathing easier. The nurse is engaging in which phase of the nursing process?

Evaluating

A client comes to the health care provider's office reporting abdominal pain, for which the client has previously sought care. Which type of assessment would the nurse perform?

Focused

The primary purpose of nursing diagnosis is to :

Guide selection of nursing interventions to meet expected outcomes

The nurse is using an assessment guide that includes a hierarchy of 5 life requirements universal to all persons. Which model for organizing assessment data is the nurse using?

Human Needs - Maslow's

Giving medication occurs in which step of the nursing process?

Implementation

Based on an established plan of care, a nurse turns a client every 2 hours. Which part of the nursing process is the nurse using?

Implementing

A nurse administers a medication for pain but forgets to document in the client's health care record. Legally, what does this mean?

In the eyes of the law, if it is not documented, it was not done

The nurse, orienting a new client to the facility, explains that the staff will ask for and honor the client's preferences and choices while providing care. This represents which expectation of the health care environment?

Individualization

The client is being seen for chest congestion, coughing up thick secretions, and shortness of breath for several days and is diagnosed with pneumonia. The client has a 2-pack per day smoking habit. When developing the plan of care, what would be a priority nursing diagnosis for this client?

Ineffective Airway Clearance related to tracheobronchial secretions as evidenced by expectorating thick, yellow secretions

The nurse recognizes that identifying outcomes / goals must include:

Involvement of the client and family

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?

Make recommendations of revising the plan of care

Which are subjective client data gathered during assessments?

Nausea, abdominal pain

What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's orders)?

Nurses do carry out interventions in response to a health care provider's orders

What is the PRIORITY goal of interventions for a risk diagnosis?

Prevent an actual problem

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 lunch and successfully drew up and administered the insulin while the nurse observed. How should the nurse follow up this observation?

Record an evaluative statement in the client's plan of care

Which accurately identifies the characteristics of effective client goals represented in the acronym "SMART"?

S = specific M = measurable R = realistic T = timebound

After completing an assessment of a client, which finding should the nurse determine is the PRIORITY for care?

Severe bleeding from a wound

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful?

The client is free of falls

A risk nursing diagnosis indicates that:

The client is more vulnerable to a certain problem than other individuals are.

Which is a correctly written client outcome?

The client will ambulate 10 ft with a walker by October 12th

A nurse delegates a specific intervention to the unlicensed assistive personnel (UAP). What implications does this have for the nurse?

The nurse transfers responsibility but is accountable for the outcome

Adherence to defined principles is recommended when delegating care tasks to assistive personnel. According to these principles, who is responsible and accountable for nursing practice?

The registered nurse

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 2nd assessment?

Time-Lapse

When documenting subjective data, the nurse should:

Use the client's own words placed in quotation marks

The nurse performs discharge teaching for a client. How would the nurse best evaluate the effectiveness of the discharge teaching?

Ask the client to repeat back to the nurse how care will be conducted at home

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the health care providers wrote orders to ambulate the client, whereas another health care provider ordered strict bed rest for the client. How would the nurse MOST appropriately remedy this conflict?

Communicate with the health care providers to coordinate their orders

A nurse recently attended a conference that focused on management of acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information from the conference. Which resource is the nurse using to enhance practice?

Evidence-based practice

Which client care concern is clearly a nursing responsibility?

Monitoring health status changes