N3010 Exam 2 Practice Questions

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to: a. complete the postoperative assessment. b. evaluate the abdominal dressing for drainage. c. administer pain medication. d. expect the client to be drowsy, and let the client rest.

a

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning? a. Ongoing b. Initial c. Discharge d. Outcome

a

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using? a. A standardized care plan b. An order set c. Guidelines d. An algorithm

a

Which is the priority question for the nurse to consider before implementing a new intervention? a. Does this treatment make sense for this client? b. How much experience do I have with this treatment? c. What equipment do I need? d. Will I need someone to assist me?

a

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source? a. Primary b. Secondary c. Tertiary d. Quaternary

b

A nurse takes an adult client's pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the nurse do next? a. Record the pulse rate on the appropriate vital signs sheet in the chart. b. Ask another nurse to take the pulse. c. Assess the client's blood oxygen saturation level. d. Wait 4 hours and take the client's pulse again.

b

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: a. identifies the unhealthy response preventing desired change. b. identifies factors causing undesirable response and preventing desired change. c. suggests client goals to promote desired change. d. identifies client strengths.

b

When the nurse inspects a postoperative incision site for infection, which type of assessment is the nurse performing? a. Complete b. Focused c. General d. Time-lapse

b

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking? a. Accuracy b. Clarity c. Precision d. Relevance

b

The nurse is performing an admission assessment on a young client admitted to the unit. Which are considered objective data? Select all that apply. a. "My leg hurts." b. 38-year-old man c. Height: 6 ft (1.82 m) d. "I am afraid something serious is wrong." e. Weight: 195 lb (89 kg)

b, c, d

A client diagnosed with advanced lung cancer has a nursing diagnosis of Ineffective Coping. What assessment data would provide evidence to the nurse for this diagnosis? a. The client asks about hospice services. b. The client makes funeral plans. c. The client states, "I am sure the doctors have misdiagnosed me." d. The client states, "I hope that I am able to attend my daughter's wedding."

c

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? a. Knowledge Deficit related to effects of chemical plant pollution b. Deficient Community Health related to chemical plant c. Risk for Community Contamination related to possible environmental pollution d. Risk for Infection related to community contamination

c

When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action? a. Inform the client that it is not necessary to wash hands before vital signs. b. Reassure the client that the nurse knows when to perform hand hygiene. c. Praise the client for taking an active role in the client's care. d. Tell the client that gloves are required for this procedure.

c

Which is an independent (nurse-initiated) action? a. Executing physician orders for a catheter b. Meeting with other health care professionals to discuss a client c. Helping to allay a client's fears about surgery d. Administering medication to a client

c

Which are examples of subjective data? Select all that apply. a. A nurse observes a client wringing the hands before signing a consent for surgery. b. A nurse observes redness and swelling at an intravenous site. c. A client describes pain as an 8 on the pain assessment scale. d. A client feels nauseated after eating breakfast. e. A client's blood pressure is elevated following physical activity. f. A client reports being cold and requests an extra blanket.

c, d, f

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition? a. The client b. The client's physician c. The client's chart d. The nursing and medical literature

d

The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client? a. Social isolation b. Powerlessness c. Chronic pain d. Disturbed sleep pattern e. Hyperthermia

d

The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data? a. During the collection of data only b. At the end of the data-gathering process c. In the middle of the data-gathering process d. Both during the collection and at the end of the collection

d

What is the most important reason for the nurse to develop critical thinking and clinical reasoning? a. To be able to employ the nursing process in client care b. To meet the requirements of the licensing examination c. To become the experts in care whom clients deserve d. To provide quality care with nursing ability and knowledge

d

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate? a. "Inadequate skills" b. "Great response" c. "Extremely well-mannered" d. "Demonstrated steps"

d

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 is breathing easier. The nurse is engaging in which phase of the nursing process? a. Assessing b. Diagnosing c. Planning d. Implementing e. Evaluating

e

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action? a. Coordinate with the other disciplines to schedule the tests with adequate rest for the client. b. Coordinate with the other disciplines to determine if all the tests scheduled are necessary. c. Review the physician's progress notes to determine if any of the tests are not indicated. d. Instruct the client to refuse the diagnostic tests if the client becomes too fatigued.

a

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem? a. Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis b. Disturbed Self-Concept related to pancreatic cancer diagnosis c. Ineffective Health Maintenance related to being overwhelmed by cancer diagnosis d. Knowledge Deficit: Cancer treatment options related to new diagnosis

a

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care? a. Reassess the client to determine the effectiveness of the interventions. b. Instruct the client that pain medication is available at regular intervals. c. Notify the physician that the client has required pain medications. d. Perform additional nonpharmacological pain interventions.

a

A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which aspect of the nurse's execution of this order demonstrates technical skill? a. Starting a new, large-gauge intravenous site on the client and priming the infusion tubing b. Understanding the Rh system that underlies the client's blood type c. Ensuring that informed consent has been obtained and properly filed in the client's chart d. Explaining the process that will be involved in preparing and administering the transfusion

a

A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action? a. Report the findings to the physician for further plans. b. Reinforce the instructions for the treatment regimen to the client. c. Interview the family to determine if the client is giving accurate information. d. Inform the client that the blood pressure medication will have to be changed.

a

A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action? a. Tell the UAP that the RN will assist the UAP with the client's ambulation. b. Tell the UAP that a different UAP should ambulate the client. c. Tell the UAP not to ambulate the client at this time. d. Tell the UAP to ask the client whether the client is comfortable with the UAP assisting ambulation.

a

A nurse is interviewing an older adult client who has experienced a drastic weight loss following a cerebrovascular accident (CVA). The client states, "I have trouble getting groceries because I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis? a. Imbalanced Nutrition: Less than Body Requirements related to difficulty in procuring food b. Imbalanced Nutrition: Less than Body Requirements related to drastic weight loss c. Imbalanced Nutrition: Less than Body Requirements related to CVA d. Imbalanced Nutrition: Less than Body Requirements related to decreased appetite

a

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? a. A client with a high fever receiving intravenous fluids, antibiotics, and oxygen b. An older adult with pneumonia who is being discharged to the son's home tomorrow c. A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall d. An adult client who is being treated for kidney stones

a

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? a. Supportive b. Psychosocial c. Coordinating d. Supervisory

a

An obese client is in the clinic to start on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for the client? The client will: a. create an exercise plan that is realistic and valued. b. exercise every day for at least 30 minutes. c. only eat three meals per day. d. stop eating meat and walk every day after dinner.

a

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action? a. Collaborate with other disciplines to revise the discharge plans. b. Instruct the client to make alternate living arrangements. c. Communicate with the physician about additional orders. d. Inform the family that it is not possible to change the discharge plans.

a

Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 ft (30 m) without the use of mobility aids by 12DEC." Several nurses have evaluated the client's progression towards this outcome at various points during care. Which evaluative statement is most appropriate? a. "12DEC - Outcome partially met. Client ambulated 75 ft (22.5 m) without the use of mobility aids" b. "12DEC - Outcome unmet. Client's ambulation remains inadequate." c. "12DEC - Outcome met, but with the use of a quad cane to assist ambulation." d. "12DEC - Outcome met."

a

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? a. Assess the client's response to the ambulation. b. Inform the client when ambulation is scheduled next. c. Discuss the client's feelings about the illness. d. Document the client's ambulation.

a

The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated? a. Planning; implementing b. Assessing; diagnosing c. Diagnosing; implementing d. Implementing; evaluation

a

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client? a. Ineffective Breastfeeding b. Disturbed Sleep Pattern c. Impaired Comfort d. Risk for Impaired Parenting e. Readiness for Enhanced Parenting

a

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? 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.

a

The nurse is caring for an underweight client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client? a. Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats b. Administer a daily multivitamin c. Monitor for allergies d. Weigh client as needed

a

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? a. Activity and rest b. Health promotion c. Nutrition d. Self-perception

a

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? a. Assess the client's blood pressure to determine if the medication is indicated. b. Determine the client's reaction to the medication in the past. c. Ask the client to verbalize the purpose of the medication. d. Tell the client to report any side effects experienced.

a

The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action? a. Reschedule the client's bath to the evening shift. b. Ask the client for permission to give the bath in the morning. c. Tell the client that the physician has ordered sleep medication if necessary. d. Determine whether the nurses have time to give the client's bath at night.

a

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do? a. Delay the instruction until the visitors leave. b. Give the visitors instructions to leave in 10 minutes. c. Ask the client if the client has any questions. d. Leave written information for the client to read later.

a

The nurse prepares a concept map for a client who is newly diagnosed with atrial fibrillation. According to the concept map pictured above, what is the highest prioritized nursing diagnosis? a. Decreased cardiac output b. Anxiety c. Deficient knowledge d. Risk for bleeding

a

The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use? a. Trial-and-error problem solving b. Intuitive thinking c. Scientific problem solving d. Critical thinking

a

When the nurse assesses the client's blood glucose level, what is the term for the type of skill the nurse is using? a. Technical b. Cognitive c. Ethical d. Interpersonal

a

Which factor is most likely to contribute to the nurse making a diagnostic error? a. The client withholds information during the client assessment. b. The client's subjective and objective data are congruent. c. The subjective and objective data point to a specific health issue. d. The client expands on information previously provided.

a

Which is an example of a long-term goal for a client with asthma? a. The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. b. By day 3 of hospitalization, the client will verbalize knowledge of factors that exacerbate the symptoms of asthma. c. Within 1 hour after a nebulizer treatment, adventitious breath sounds and cough will decrease. d. Within 72 hours after admission, the client's respiratory rate will return to normal and retractions disappear.

a

Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)? a. Does this task fall within the scope of a UAP? b. What is the client's condition? c. How can I supervise the completion of this task? d. How can I explain the task to the UAP?

a

Which nursing action can be categorized as a surveillance or monitoring intervention? a. Auscultating of bilateral lung sounds b. Providing hygiene c. Administering a paracetamol tablet d. Use of therapeutic communication skills

a

Which statement best conveys the role of intuition in nurses' problem solving? a. Intuition can be a clinically useful adjunct to logical problem solving. b. Intuition is an unreliable mode of thinking that should be avoided. c. In experienced nurses, intuition can be a valid replacement for scientific problem solving. d. Intuition is reliable when those nurses implementing it have a special "gift."

a

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. "I dropped the strips for my fingerstick blood glucose testing in the bath water." d. "My social security check does not come until next week e. "My daughter helps me with my range-of-motion exercises every morning and afternoon."

a, c, d

A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment? a. Document that the client is talking back to the voices in the client's head. b. Document this assessment based on the client's behaviors. c. Do not document this assessment because the client could be using a wireless device to talk to family. d. Do not document this assessment because it is subjective.

b

A home health nurse reviews the nursing care plan with the client and family. Then they mutually discuss the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating? a. Diagnosing b. Planning c. Implementing d. Evaluating

b

A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse? a. The nurse evaluates the plan of care. b. The nurse evaluates the client's goal/outcome achievement. c. The nurse evaluates the competence of nurse practitioners. d. The nurse evaluates the types of health care services available to the client.

b

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."

b

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? a. Ask the client to verbally repeat the steps of the injection. b. Ask the client to demonstrate self-injection of insulin. c. Ask family members how much trouble the client is having with injections. d. Ask the client how comfortable the client is with injections.

b

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care? a. Consult with another nurse. b. Seek research about the disorder. c. Follow institutional guidelines. d. Set priorities using client care standards.

b

A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care? a. Another nurse manager b. Another registered nurse with critical care certification c. One of the staff critical care physicians d. Another staff nurse from the medical-surgical unit

b

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem? a. Reprimand the nursing personnel responsible for the clients when the falls occurred. b. Investigate the circumstances that contributed to client falls. c. Institute a new policy on the prevention of client falls on the unit. d. Determine if client falls have increased on other units in the hospital.

b

A resident of a long-term care facility refuses to eat until the client has had hair combed and makeup 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

b

At the beginning of prenatal care, the goal for the client was to gain 25 lb (11.25 kg) by the end of the pregnancy. At 30 weeks of pregnancy, the client has only gained 1 lb (0.45 kg). Which statement(s) would help the nurse most appropriately interpret these data? a. It is too early to evaluate if the goal has been achieved. The client has 10 more weeks of pregnancy. b. The client is not achieving the goal. The nurse should determine the reasons the client has not been gaining weight. c. The client is progressing toward achieving the goal. The plan should be continued. d. The client has partially achieved the determined goal. The nurse should revise the goal to reflect a more realistic outcome.

b

In which situation would the nurse be most justified in implementing trial-and-error problem solving? a. The nurse is attempting to determine the range of motion of a client's hip joint following hip surgery. b. The nurse is attempting to landmark an obese client's apical pulse. c. The nurse is attempting to determine which as-needed analgesic to offer a client who is in pain. d. The nurse is attempting to determine whether a poststroke client has a swallowing deficit.

b

The client demonstrates stair climbing using a quad cane. This is an example of: a. an affective outcome. b. a psychomotor outcome. c. a physiologic outcome. d. a cognitive outcome.

b

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action? a. Teach the content again utilizing the same method. b. Reassess the appropriateness of the method of instruction. c. Revise the plan to include the inclusion of a support group. d. Report the client's inability to learn to the case manager.

b

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value? a. Subjective b. Objective c. Primary d. Secondary

b

The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action? a. During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. b. Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. c. After turning the client alone, the nurse realizes that the nurse should have insisted on having help. d. The nurse decides to turn the client every 4 hours because everyone is too busy to help.

b

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include? a. Medications used to treat diabetes mellitus b. Risk factors for and prevention of diabetes mellitus c. The severity of the client's disease d. The cellular metabolism of glucose

b

The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to: a. examine certain body systems. b. complete an exam of all body systems. c. perform a review of the problem areas. d. focus on only the systems that the client is comfortable with.

b

The outcome statement on an infant's plan of care is "The mother will explain proper nutrition for infants." This is an example of which type of outcome statement? a. Psychomotor b. Cognitive c. Affective d. Physical changes

b

What should the nurse do prior to performing an initial assessment on a newly admitted client? a. Introduce the members of the health care team to the client. b. Review the records available on the client. c. Report to the charge nurse what needs to be done for the client. d. Tell the client that the nurse will do an assessment only if it's convenient.

b

When performing an assessment, the nurse should focus most on the developmental stage for which client? a. Young adult b. Toddler c. Middle-age adult d. Adolescent

b

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours? a. Client reports no headache. b. Client is drowsy after lunch c. Client is normotensive. d. Client lipids are within range.

c

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis? a. Problem-focused b. Risk c. Health Promotion d. Syndrome

c

A nurse is changing a sterile pressure injury 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

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which statement 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

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing? a. Complete b. Focused c. Time-lapse d. Emergency

c

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status? a. "My daughter has been staying with me the past few weeks." b. "I asked my neighbors to help me with my yard work." c. "My wife's been gone for about 7 months now. d. "I sort my medication into an organizer every week."

c

During a home health care visit, the nurse identifies a nursing diagnosis of Caregiver Role Strain for a parent who is caring for a child dependent on a ventilator. What subjective assessment data would support the nurse's diagnosis? a. The parent states, "I make sure that I get regular exercise." b. The parent states, "A member of my church gives me a break twice a week." c. The parent states, "I cannot allow anyone else to help because they won't do it right." d. The parent states, "I attend support group meetings when I am able to go."

c

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue? a. The nurse should determine the length of time the client has been in the hospital. b. The nurse should determine what laboratory tests are critical at this time. c. The nurse should determine the reason for the client's refusal. d. The nurse should determine the client's last laboratory results.

c

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? a. Providing medication for agitation b. Repositioning to prevent pressure injuries c. Ensuring that the endotracheal tube is secure d. Changing the dressing to prevent infection

c

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 physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict? a. Assess the client to determine whether the client is capable of ambulation. b. Instruct the client to ask the physicians for clarifications of instructions. c. Communicate with the physicians to coordinate their orders. d. Collaborate with the physical therapist to determine the client's ability.

c

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining? a. Process b. Structure c. Outcome d. Cost-effectiveness

c

The nurse is conducting an interview with a newly admitted client. Which listening behavior should the nurse implement to have a successful interview? a. Focus mainly on verbal comments. b. Fill in the words for the client. c. Avoid the impulse to interrupt. d. Fill in quiet spaces and pauses.

c

The nurse on a busy acute care floor identifies that several clients with heart failure are being readmitted within 2 weeks of discharge. Which step in performance improvement is the nurse demonstrating? a. Planning a strategy using indicators b. Implementing a change c. Discovering a problem d. Assessing the change

c

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? a. Control b. Transparency c. Individualization d. Safety

c

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? a. The client who needs vital signs taken following infusion of packed red blood cells. b. The client who requires assistance dressing in preparation for discharge. c. The client with continuous pulse oximetry who requires pharyngeal suctioning. d. The client who is pleasantly confused and requires assistance to the bathroom.

c

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? a. Remind the client that the client is responsible for the client's own health care decisions. b. Ask the client whether the client is afraid that the spouse will be angry. c. Ask the surgeon to wait until the client has had a chance to talk to the spouse. d. Inform the surgeon that the nurse will not sign the informed consent form.

c

While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate? a. Document on the client's chart that the assessment data may be biased. b. Inform the client of these potential biases and obtain the client's opinion. c. Consult with another nurse for that colleague's description of the assessment or observations. d. Verify the information with one or two family members without informing the client.

c

A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement? a. Psychomotor b. Cognitive c. Affective d. Physical changes

d

A new nurse is ambulating a client for the first time after surgery. What should the nurse do to anticipate and help prevent an unexpected outcome? a. Take the client's vital signs after ambulation. b. Ask the client's spouse to assist with ambulation. c. Delay ambulation until the following shift. d. Ask another nurse to help with ambulation.

d

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome? a. Choosing actions that do not solve the problem b. Failing to update the written plan of care c. Beginning the plan without family help d. Developing the plan without client input

d

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? a. Surveillance b. Maintenance c. Supervisory d. Educational

d

After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data? a. Functional Health Patterns b. Human Response Patterns c. Body Systems Model d. Hierarchy of Human Needs

d

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which question is the most appropriate conclusion to the interview? a. "What are your expectations from us and from yourself in your care?" b. "What practices have you found especially helpful in other settings?" c. "What do you envision for your care while you're here at the facility?" d. "Is there anything else we should know in order to care for you better?"

d

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met? a. "I will take insulin until my blood sugar levels are normal." b. "I will take my medications between meals for maximum effect." c. "I will mix insulin glargine with insulin lispro at bedtime." d. "I will test my glucose level before meals and use sliding scale insulin."

d

Which is a characteristic of person-centered care? a. It is independent of other disciplines. b. It can be used in hospital settings. c. It involves general care for all clients. d. It is a framework for providing care.

d

Which nursing action reflects evaluation? a. The nurse identifies that the client has wound drainage. b. The nurse sets an anxiety level of 3 or less with the client. c. The nurse performs colostomy irrigation. d. The nurse assesses the client's response to pain medication.

d

Which scenario is an example of a time-lapse reassessment? a. Seeing a client down on the floor, the nurse assesses the client's airway, breathing, and circulation, calls for help, and begins a quick neurological exam. b. A nurse just coming on shift performs a focused physical assessment on each client, based on the client's diagnosis. c. A nurse in a long-term skilled nursing facility assesses a new resident's baseline health status. d. A nurse assesses a client with mobility issues to see how the client is doing with fall prevention strategies they practiced before.

d

An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client? a. Developmental stage assessment b. Time-lapsed assessment c. Emergency assessment d. Focused assessment

b

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention? a. Supportive b. Surveillance c. Collaborative d. Maintenance

b

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? a. Physiologic b. Safety and security c. Love and belonging d. Self-esteem e. Self-actualization

b

Which action should the nurse take when client data indicate that the stated goals have not been achieved? a. Collect more data for the database. b. Review each preceding step of the nursing process. c. Implement a standardized plan of care. d. Change the nursing orders.

b

Which assessment findings would support the nursing diagnosis of Acute Pain? Select all that apply. a. The client had an abdominal hysterectomy 1 day ago. b. The client is crying in pain about 20 minutes before pain medicine is due. c. The client has a history of osteoarthritis. d. The client had back surgery 2 years ago and expresses the need for ibuprofen on most days. e. The client is a heavy cigarette smoker.

b

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which nursing diagnosis 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

A nurse suspects that a client has a self-care deficit, but needs more data to confirm this diagnosis. What nursing diagnosis would the nurse write for this client? a. Actual b. Potential c. Possible d. Apparent

c

Which nursing diagnosis is an example of a health promotion diagnosis? a. Acute pain b. Risk for Infection c. Readiness for Enhanced Parenting d. Possible Chronic Low Self-Esteem

c

A nurse is asked to perform a skill for which the nurse is not prepared. When using the method of critical thinking, what would be the first step to resolve the situation? a. Purpose of thinking b. Adequacy of knowledge c. Potential problems d. Helpful resources

a

"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis? a. Actual nursing diagnosis b. Risk nursing diagnosis c. Health promotion nursing diagnosis d. Potential nursing diagnosis

a

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? a. Narcotic analgesic to treat pain b. Septic workup due to blood pressure and heart rate elevation c. Isolation for suspected respiratory illness d. Acetaminophen to treat pain and fever

a

A 19-year-old college basketball player is being evaluated for injuries after a skiing accident. The nurse determines that the client has a pulse of 52 beats/min. What would be the most appropriate way for the nurse to determine the significance of the client's heart rate? a. Ask the client whether the heart rate is normal for the client. b. Compare the client's heart rate to that another teenaged client. c. Have another nurse reassess the heart rate for accuracy. d. Determine whether the client has any risk factors for cardiac disease.

a

A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse most effectively meet this client's need? a. Collaborate with other disciplines to determine the best way to meet the client's medication requirements. b. Reinforce to the client and family the necessity of taking all medication as ordered to stabilize the client's condition. c. Inform the physician of the need to prescribe a less expensive medication for the client's condition. d. Instruct the client that some pharmaceutical companies have programs to help with medication expenses.

a

Which is an actual nursing diagnosis? a. Impaired Urinary Elimination b. Readiness for Enhanced Sleep c. Risk for Infection d. Possible Impaired Adjustment

a

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address? a. PC: Decreased Cardiac Output related to cardiac tissue damage b. PC: Disturbed Body Image related to decreased activity tolerance c. PC: Activity Intolerance related to decreased oxygenation capacity d. PC: Fear related to new diagnosis of myocardial infarction

a

A client is brought to the emergency department in an unconscious condition. The client's spouse hands over the previous medical files and points out that the client suddenly fell unconscious after trying to get out of bed. Which is a primary source of information in this case? a. The client's spouse b. The client's medical documents c. The client's test results d. The client's assessment data

a

A client is caring for the client's mother-in-law, who is an older adult who requires assistance with peforming activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain? a. "I just don't have time to take a shower." b. "I feel great but wish that I could get more sleep." c. "My mother-in-law and I go for a walk daily." d. "My mother-in-law makes dinner on Tuesdays, and I cannot stand her cooking."

a

A client is on the surgical unit following resection of an intestinal tumor. The client is alert and oriented x3. Based on an assessment of the client, the physician writes a medical order to "ambulate with assistance" in the chart. This will be the client's first time ambulating. Which is the best nursing outcome for this client? a. The client will ambulate with the assistance of a walker without falling within the next 4 hours. b. Physical therapy will be consulted to assist the client with ambulation c. The client will ambulate to the restroom 3 times this shift d. The client will ambulate with the assistance of a walker sometime today.

a

A client is receiving care on a rehabilitative medicine unit during recovery from a stroke. The client voices frustration 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 all professionals to perform bedside assessments and interventions simultaneously, rather than individually.

a

A client is scheduled to be fitted with a prosthesis following the loss of the nondominant hand after a traumatic injury. Nurses have documented an outcome that states, "After attending multiple educational sessions, the client will demonstrate correct technique for applying the prosthesis." Which statement by the client would indicate a need to revise the plan of care related to this outcome? a. "I'm not interested in wearing an artificial hand." b. "People are going to look at me when I wear this thing." c. "This doesn't look like my other hand." d. "I don't understand the technology that's used in this artificial hand."

a

A client reports to the nurse quitting smoking 6 months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome? a. Affective b. Cognitive c. Psychomotor d. Phsyiologic

a

A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach the client about the management of the 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

A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective? a. Client will use chin tuck and double swallow for each bite. b. Client will avoid straws and drink thickened liquids. c. Client will sit in chair for all meals and snacks. d. Client will chew food well and use a tongue sweep.

a

A client with congestive heart failure has dyspnea while ambulating to the bathroom. The nurse selects the nursing diagnosis of "Activity Intolerance" to address this health problem. Which etiology would be appropriate to select for this nursing diagnosis? a. Compromised oxygen transport b. Inadequate motivation c. Cardiac disease d. Fluid overload

a

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? a. Client will have formed stools within 24 hours. b. Client will eat small meals of bland foods for 3 days. c. Client will identify the food that caused the condition within 3 hours. d. Client will maintain adequate hydration within 2 days.

a

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? a. On the client's admission to the hospital b. Once the client has received a discharge order c. As soon as possible after the client's surgery d. Once the client is admitted to the nursing unit from postanesthetic recovery

a

A community group has requested the public health nurse to present a program describing the advised schedule of immunizations for children. To plan for this program, what nursing diagnosis would be most appropriate for the nurse to select? a. Readiness for Enhanced Knowledge: Childhood Immunizations b. Ineffective Health Maintenance related to lack of knowledge of childhood immunizations c. Risk for Infection Transmission related to lack of immunizations d. Risk for Complications related to childhood illnesses

a

A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed: a. Peer review b. Quality and Safety Educatin for Nurses (QSEN) c. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) d. American Association of Critical-Care Nurses (AACN)

a

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem? a. Client will not leave the premises without a caregiver. b. Client will wear an ID bracelet with name and contact information. c. Client will identify landmarks that indicate location of home. d. Client will consistently return to the police station when lost.

a

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify? a. Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor b. Homelessness Syndrome related to lack of housing as evidenced by visibly soiled clothing c. Inadequate Hygiene related to homelessness as evidenced by client's stink d. Impaired Impulse Control related to poor socioeconomic conditions as evidenced by visibly soiled clothing

a

A large university hospital has commissioned a multidisciplinary group to review client records following discharge to evaluate client outcomes and the character and quality of nursing care that clients receive. Which type of evauation process will take place? a. A nursing audit b. An accreditation inspection c. A structure evaluation d. A process evaluation

a

A nurse identifies the following nursing diagnosis for a client with an infected leg ulcer: "Deficient Knowledge related to diminished peripheral circulation and wound care as evidenced by recurrent infected leg ulcer." Which statement would the nurse identify as addressing a cognitive outcome? a. "The client states the reason for wound care measures." b. "The client demonstrates how to irrigate leg wound." c. "Client chooses correct size of dressing to cover the wound." d. "Client verbalizes being motivated to continue follow-up to prevent recurrence."

a

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified: a. outcome. b. subjective data. c. nursing diagnosis. d. intervention.

a

A nurse in a community health center has been having regular meetings with a client who wants to stop smoking. Which outcome decision option should the nurse document if the client has not smoked for 7 months? a. Outcome met b. Outcome partially met c. Outcome not met d. Outcome inappropriate

a

Which are examples of subjective data? Select all that apply. a. Anxiety b. Light-headedness c. Nausea d. Edema e. Laceration

a, b, c

A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. The cast is bivalved and capillary refill is observed at 2 seconds. What is the best modification to the care plan by the nurse? a. Perform hourly neurovascular assessment. b. Elevate the injured arm on a pillow. c. Apply ice to the casted extremity. d. Give prescribed pain meds.

a

A nurse is caring for a client admitted with dehydration after completing a triathlon in a hot, dry climate. The nurse identifies an appropriate nursing diagnosis for this client as "Deficient Fluid Volume related to insufficient fluid intake as evidenced by blood pressure of 84/46 mm Hg, heart rate of 145 beats/min, concentrated urine, and client reporting drinking 200 mL of water during the 4-hour event." Which is the problem statement in this nursing diagnosis? a. Deficient fluid volume b. Insufficient fluid intake c. Blood pressure of 84/46 mm Hg, heart rate of 145 beats/min, concentrated urine d. Hot, dry climate

a

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care? a. Add the nursing diagnosis: Risk for Self-Harm. b. Tell another nurse about this client statement. c. Encourage the client to join a therapy group. d. Document that the depression has resolved.

a

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse? a. Encourage hourly use of the incentive spirometer. b. Promote oral fluid intake between meals. c. Provide oral pain medication before ambulation. d. Reassess in 4 hours and document the findings.

a

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which nursing intervention best demonstrates caring in this situation? a. Assisting the client to sit up in a chair b. Assessing the abdominal incision c. Monitoring vital signs d. Notifying the health care provider of lab results

a

A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern? a. Risk for Powerlessness b. Disturbed Body Image c. Impaired Comfort d. Risk for Suicide

a

A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask? a. "What happened?" b. "How did the client value the experience?" c. "Were assumptions made correctly?" d. "How did the client perceive the event?"

a

A nurse is evaluating a client to determine outcome achievement. The nurse determines that the client's outcome was partially met. When documenting the evaluative statement, the nurse records which other information? a. Data that support the decision of the outcome being partially met b. The client's verbal agreement of the outcome not being met c. The reason the outcome was only partially met d. The revision to the initial outcome identified

a

A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which action 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.

a

A nurse is interviewing a new client admitted to the hospital for surgery. Which action would the nurse perform in the introductory phase of the interview? a. The nurse assesses the client's comfort and ability to participate in the interview. b. The nurse recapitulates the interview, highlighting important points. c. The nurse asks the client if there is anything else that needs to be divulged d. The nurse gathers all the information needed to form the subjective database.

a

A nurse is performing an assessment on a client in which the nurse categorizes the data according to various categories of functions. Which assessment model is the nurse using? a. Gordon's functional health patterns b. Maslow's hierarchy c. Medical d. Prevention

a

A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care? a. Include the client and the client's power of attorney in the discussion. b. Ask the client what the priority needs are. c. Consult the oncology nurse specialist in order to determine priorities. d. Hold a unit meeting to determine needs.

a

A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing, for which the nurse identifies several nursing diagnostic labels, including Ineffective Breathing Pattern and Impaired Gas Exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern? a. Activity-exercise b. Nutritional-metabolic c. Coping-stress tolerance d. Cognitive-perceptual

a

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

a

A nurse is working as part of a quality assurance team that uses the American Nurses Association model. The team is evaluating the resources of the facility as well as the physical facilities and equipment. Which type of evaluation is the team engaged in? a. Structure evaluation b. Process evaluation c. Outcome evaluation d. Quality by inspection

a

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? a. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. b. The nurse will help the client ambulate the length of the hallway once a day. c. Offer to help the client walk the length of the hallway each day. d. The client will become mobile within a 24-hour period.

a

A nurse plans a series of muscle-strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. The client is unsuccessful when the new strategies are implemented. Which action by the nurse may have led to failure to meet the outcome? a. Choosing actions that do not solve the problem b. Failing to update the written plan of care c. Beginning the plan without family to help d. Stating outcomes too broadly

a

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? a. Evidence-based practice b. Clinical experience c. Current medical practice d. Ethical and legal guides to practice

a

A nurse should have critical thinking attitudes to develop critical thinking skills. One attitude the nurse should possess is orderly thinking to do what is best. Which term best suits this attitude description? a. Discipline b. Persevereance c. Integrity d. Humility

a

A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." Which 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. Is made when not enough evidence supports the problem

a

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action? a. The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client. b. The nurse should ask another nurse who was previously assigned to the client for instruction. c. The nurse should request that the blood transfusions be delayed until the next shift. d. The nurse should recognize the necessity of the assignment and provide care to the best of the nurse's ability.

a

A nurse writes the following nursing diagnosis for a client with Alzheimer disease: Disturbed Thought Processes related to Alzheimer 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 disease d. Incoherent language

a

A teenager on life support after a diving accident has no brain wave activity. The parents tell the nurse they are sure their child will wake up soon. Which nursing diagnosis would the nurse identify to assist the parents of the child? a. Interrupted Family Processes related to inability to accept their child's inevitable death as evidenced by the parents' statement that their child will wake soon b. Interrupted Family Processes related to brain death of their child as evidenced by parents' refusal to accept the inevitable c. Death Anxiety related to anticipated death of child as evidenced by child having no brain wave activity d. Death Anxiety related to dysfunctional family processes as evidenced by parents' refusal to acknowledge the child's condition

a

After a month of pursuing a new nutiritonal and exercise plan to lose weight, a client has lost 2 lb (0.90 kg) of the 5 lb/month (2.25 kg/month) goal. How should the nurse alter the plan of care in response to this new data? a. The nurse should not alter the plan of care. b. The nurse should change the diet. c. The nurse should delete the nursing diagnosis. d. The nurse should modify the time criteria.

a

At 0730, the nurse notes that the client states that pain is a 7 on a scale of 0 to 10. Based on this assessment, the nurse administers pain medication to the client. At 0800, the nurse evaluates the client and finds that pain is a 4 on a scale of 0 to 10. Which example of documentation most clearly communicates the initial morning assessment? a. 0730: Client reports pain is a 7 on a scale of 0-10. Morphine sulfate 2 mg IV administered. b. 0730: Client states that pain is severe. Pain medication administered. c. 0900: Client states pain from 0730 has decreased from a 7 to a 4 after medication was administered. d. 0800: Client states that pain has decreased.

a

Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement? a. Psychomotor b. Cognitive c. Affective d. Physical changes

a

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? a. Go to the client and assess the client's pain. b. Determine the frequency of pain medication. c. Medicate the client with the ordered pain medication. d. Instruct the client in nonpharmacologic pain management.

a

During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to: a. body systems. b. functional health patterns. c. human response patterns. d. human needs.

a

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill? a. Intellectual b. Technical c. Interpersonal d. Visual

a

Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal? a. Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. b. Assist the client to put on the clothing that goes over the operated leg. c. Tell the client's family to bring in clothes a size larger to make dressing easier. d. Arrange for the social worker to schedule home health care with discharge planning.

a

For which client would a standardized plan of care most likely be appropriate? a. A client who was admitted for shortness of breath and who has been diagnosed with pneumonia b. A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy c. A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem d. A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident

a

How should a nurse best document the assessment findings that have caused the nurse to suspect that a client is depressed following a below-the-knee amputation? a. "Client states, 'I don't see the point in trying anymore.'" b. "Client makes statements indicating a loss of hope." c. "Client states that rehabilitation will be unsuccessful." d. "Client is demonstrating signs and symptoms of depression."

a

Nurses on an orthopedic nursing unit use standardized care plans that incorporate nursing, physical therapy, occupational therapy, and case management actions for clients who experience a particular surgery. Which type of care plan do these nurses use? a. Clinical pathway b. Computer database c. Nursing diagnosis d. Concept map

a

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? a. Encourage the client to provide as much self-care as possible. b. Perform all care activities for the client to facilitate rest. c. Teach the family to anticipate the client's needs to care for the client. d. Arrange with the nurse case manager for an early discharge.

a

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate? a. Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement b. Hopelessness related to inability to decide a course of action as evidenced by the client's statement c. Complicated Grieving related to mental trauma as evidenced by the client's inability to make a decision d. Ineffective Coping related to rape trauma syndrome as evidenced by client's inability to make a decision

a

The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? a. Perform vital signs and blood glucose level. b. DIscuss the need to change positions slowly, especially when moving from sitting to standing. c. Perform a full review of systems. d. Initiate an intravenous line and administer 500mL of normal saline.

a

The focus of a hospital's current quality assurance program is a comparison of the health status of clients on admission and with that at the time of discharge. This form of quality assurance is characteristic of: a. outcome evaluation. b. structure evaluation c. process evaluation d. nursing audit

a

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

a

The nurse assesses a client's blood pressure, which is 160/90 mm Hg. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure, finding it to be 140/78 mm Hg. Which action has the nurse implemented? a. Evaluating b. Appraising c. Planning d. Implementing

a

The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by the client refusing to look at the surgical site and stating, "I'm ugly. My husband will no longer find me desirable." What is the etiology identified in this nursing diagnosis? a. Decreased ability to cope with surgical removal of right breast b. "I'm ugly. My husband will no longer find me desirable." c. Disturbed body image d. Refusal of the client to look at the surgical site

a

The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of a 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

The nurse has formulated the nursing diagnosis: Acute Confusion related to low serum sodium levels as evidenced by sodium 125 mEq/L for a client. What part of the nursing diagnosis is "low serum sodium levels"? a. Etiology b. Problem c. Defining characteristics d. Client need

a

The nurse has identified a collaborative problem of Risk for Complications of Electrolyte Imbalance for a client with diarrhea. The client begins to exhibit a decrease in level of consciousness. What is the nurse's most appropriate action? a. Notify the physician for additional orders. b. Document the client's level of consciousness. c. Consult with another nurse to validate the assessment. d. Decrease stimulation and allow the client to rest.

a

The nurse in a clinic located in a high-rise building on a university campus has noted that many of the homeless clients who are supposed to receive care for HIV/AIDS have missed their appointments. When questioned, several of the clients stated to the nurse that the clinic is difficult to find and in an intimidating environment. Which variable does the nurse identify as being inadequately addressed for these clients? a. Psychosocial background and culture b. Developmental stage of the clients c. Ethical and legal guides to practice d. Resources

a

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client's and family's ability to cope. What action should the nurse take with this client? a. Comfort the client and family. b. Provide more information about diabetes. c. Test the client's blood glucose levels. d. Ask the client whether anyone else in the client's family also has diabetes.

a

The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? a. "I must conduct research to validate the usefulness of my nursing interventions." b. "I can learn about evidence-based practice by reading professional nursing journals." c. "Nursing interventions should be supported by a sound scientific rationale." d. "The Agency for Healthcare Research and Quality is a resource for evidence-based practice."

a

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent? a. The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. b. The client expresses a desire to learn how to manage the medication regime. c. The parents verbalize acceptance of the need to closely monitor their child's condition. d. The parents have comprehensive insurance coverage for their family's medical care.

a

The nurse is caring for a client who has been diagnosed with a sexually transmitted infection (STI). The nurse plans to address the nursing diagnosis of Risk-Prone Behavior. What assumption has the nurse made? a. Having an STI means the client is sexually promiscuous. b. The client needs education to decrease the likelihood of repeated infection. c. Having an STI means the client is unaware of the risks of unprotected sex. d. The client does not understand the complications of STIs.

a

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping? a. Health promotion nursing diagnosis b. Actual nursing diagnosis c. Risk nursing diagnosis d. Syndrome nursing diagnosis

a

Which assessment findings would support the nursing diagnosis of Impaired Skin Integrity? Select all that apply. a. Impaired mobility due to recent stroke b. Unable to turn in bed without assistance c. Uncontrolled diabetes d. History of appendectomy e. Up with assistance to bedside commode

a, b, c

The nurse is conducting a health 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. Continue the health history with questions focusing on respiratory function. b. Consult with other members of the health care team about the conflicting client information. c. Prioritize documentation of objective data collected in the examination while avoiding any mention of the discrepancy. d. Ask significant family members about the client's usual breathing pattern at home.

a

The nurse is conducting a nursing history of a client with a respiratory rate of 30 breaths per minute, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next in regard to the discrepancy? a. Clarify discrepancies of assessment data with the client. b. Validate client data with members of the health care team. c. Document objective data collected in the physical examination; there is no need to document the discrepancy. d. Seek input from family members regarding the client's breathing at home.

a

The nurse is delegating a task 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 the normal baseline."

a

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. Which goal written by the nurse requires revision? a. The client will understand the effects of smoking related to heart disease. b. By 08/02/18, the client will state three therapeutic methods of reducing stress. c. By 8/02/18, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. d. By 8/02/18, the client will state when to notify the health care provider after discharge.

a

The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool and pale with capillary refill > 3 seconds, diminished dorsalis pedis and posterior tibial pulses, client reports cramping pain in left foot. The nurse is doing what? a. Clustering significant data cues b. Formulating a nursing diagnosis c. Validating the nursing diagnosis d. Identifying contributing factors

a

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques? a. "When did you first notice the rash on your leg?" b. "Do you have any additional questions for me?" c. "Why do you feel that way about your cancer diagnosis?" d. "Have you ever heard the saying 'no pain no gain?'"

a

The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the most appropriate nursing action? a. Assess the client's back visually. b. Document the rash in the client's chart. c. Establish a nursing diagnosis of Altered Skin Integrity. d. Report it to the health care provider.

a

The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome? a. Client will maintain nutritional intake without pain or diarrhea. b. Client will talk with campus cafeteria manager about identifying safe meals. c. Client will understand what inflammatory bowel disease is. d. Client will learn to cook foods that meet personal nutritional needs.

a

The nurse is planning the care of a client who is receiving treatment for acute renal failure and who has begun dialysis 3 times weekly. The nurse has identified the following outcome: "Client will demonstrate the appropriate care of an arteriovenous fistula." This outcome is classified as which? a. Psychomotor b. Affective c. Cognitive d. Holistic

a

The nurse is providing education to a group of middle school students regarding cold weather safety. One of the students asks the nurse how cold her body will get when it is cold outside waiting for the school bus. The nurse responds: a. "We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time." b. "You can expect your body temperature to drop about 3 degrees during your time at the bus stop." c. "When exposed to extreme cold, the body works hard to stay warm and may warm itself 1-2 degrees above normal during exposure." d. "Everyone is different so I cannot say how your body might react."

a

The nurse manager is holding a staff meeting and indicates that the unit is looking at a 3% budget cut for the coming year. The nurse manager asks the staff what they see as priorities for the unit, and solicits suggestions from the staff as to what budget areas might be reduced. Which standard for establishing and sustaining healthy work environments does this action represent? a. Effective decision making b. Micromanagement c. Appropriate staffing d. Meaningful recognition

a

The nurse manager observes one of the unit nurses failing to wash hands on entering a client room. Hospital protocol is to wash hands before and after entering a client room. This scenario is an example of which approach to quality assurance? a. Quality by inspection b. Quality as opportunity c. Quality by perception d. Quality as initiative

a

The nurse manager on an orthopedic unit has determined that the nurses are not keeping the nursing diagnoses up-to-date on client care plans and, in turn, are not using the plan of care. What is a feasible approach to correcting this problem? a. Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses. b. Request that a staff development nurse instruct the nurses on concept mapping to use instead of care planning. c. Provide an in-service on interviewing and physical assessment skills; discuss the importance of these skills with the staff. d. Delegate the updating of nursing diagnoses for all clients on the unit to one nurse for each shift.

a

The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is: a. a clinical pathway. b. an order set. c. an algorithm. d. a protocol.

a

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? a. Compare the client's pulse rate to the standard range. b. Notify the client's health care provider. c. Document the pulse in the appropriate chart page. d. Ask another nurse to verify the pulse rate.

a

The nurse uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill? a. Cognitive skill b. Technical skill c. Interpersonal skill d. Ethical or legal skill

a

The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side." This statement is an example of: a. a cue. b. an inference. c. a misinterpretation. d. duplicate data.

a

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs? a. Physiological b. Safety c. Love and belonging d. Self-actualization

a

When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next? a. Assess the client's interactions with the newborn. b. Direct all education of infant care to the client's mother. c. Initiate referrals to available community services. d. Develop a comprehensive education plan for infant care.

a

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "The client will know how to self-administer prescribed bronchodilators using a nebulizer by 09/09/2020." Why is this outcome inadequate? a. The outcome is not observable or measurable. b. The outcome is not related to an independent nursing action. c. The outcome does not specify the conditions in which it will be achieved. d. The statement expresses a client outcome as a nursing intervention.

a

Which action should the nurse take during the evaluation phase of the nursing process? a. Document reassessment of pain after medication administration. b. Provide the client with a follow-up appointment after discharge. c. Have the client give input into plan of care upon admission. d. Discontinue the indwelling urinary catheter per the provider's order.

a

Which client situation most likely warrants a time-lapse nursing assessment? a. An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. b. The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain. c. A client is being admitted to a general medicine unit after spending several days in the intensive care unit. d. A nurse is auscultating the lungs and measuring the oxygen saturation of a client who has pulmonary edema.

a

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. c. Perform tracheostomy care every 8 hours. d. Straight catheterize every 6 hours.

a

Which is an example of a psychomotor outcome? a. Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. b. Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. c. The client will verbalize understanding of the need to continue to take medications as prescribed. d. The client's skin will remain smooth, moist, and without breakdown or ulceration.

a

Which is is the priority activity for the nurse to perform in the implementation step of the nursing process? a. Reassess client's needs. b. Document nursing care. c. Prioritize evaluation of care. d. Differentiate between subjective and objective data.

a

Which outcome is sufficiently measurable? a. Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020. b. Client will progress from clear fluid diet to full fluid diet without experiencing nausea. c. Increase client's diet from clear fluids to full fluids by 12/15/2020. d. Client will maintain adequate intake with no reports of nausea by 12/15/2020.

a

Which purpose of the evaluation phase of the nursing process is a priority during client care? a. To examine the client's behavioral response to the care received b. To provide basis for the revision of plan of care c. To limit assessment to only the beginning phase of the nursing process d. To appraise the collaboration of the client and family

a

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? a. Bed bath for the newly admitted client who has multiple skin lesions b. Preparation of insulin for the diabetic client with an elevated blood glucose level c. Ambulation of the client with a history of falls for the first time after surgery d. Insertion of a urinary catheter in a client with benign prostatic hypertrophy

a

While caring for a client admitted to the hospital for a fractured tibia, the nurse notes the client's blood pressure readings are consistently higher the expected range for the client's age. How would the nurse most appropriately plan to care for this client? a. Address the collaborative problem PC: Hypertension. b. Address the nursing diagnosis, "Risk for Injury related to hypertension." c. Address the possible nursing diagnosis, "Ineffective Tissue Perfusion related to hypertension." d. Address the medical diagnosis of Hypertensive disorder.

a

Which are psychomotor outcomes? Select all that apply. a. Accurately drawing up insulin b. The client will safely ambulate using a walker. c. The client will identify signs and symptoms of infection. d. The client will rate pain as a 2 on a 0 to 10 pain rating scale. e. The client will report increased confidence in testing blood glucose level.

a, b

A nursing diagnosis of "Ineffective Coping" has been chosen for a client after receiving a diagnosis of prostate cancer. What assessments would the nurse consider as evidence for this diagnosis? Select all that apply. a. The client reports an inability to get adequate restful sleep. b. The client has difficulty concentrating on the details of treatment options. c. The client states, "I can't handle all of this." d. The client asks for information relating to the cancer diagnosis. e. The client requests the minister of the client's church to visit.

a, b, c

A nursing diagnosis of Ineffective Airway Clearance has been chosen by the nurse caring for a client with respiratory problems. Which assessment data would be appropriate evidence of this diagnosis? Select all that apply. a. Ineffective cough b. Wheezes auscultated over all lung fields c. Labored respirations d. Viral pneumonia e. Oxygen at 3 L/min per nasal cannula

a, b, c

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. a. The client's respiratory rate decreases. b. The client states, "I can breathe easier now." c. The client's oxygen saturation level increases. d. The client is watching television. e. The client's family asks if the client is going to be okay.

a, b, c

Which are cognitive client outcomes? Select all that apply. a. The client lists the side effects of digoxin. b. The client describes how to perform progressive muscle relaxation. c. The client identifies signs and symptoms of hypoglycemia. d. The client correctly ambulates with a walker. e. The client reports cycling 30 minutes three times each week.

a, b, c

Which are correctly written nursing interventions? Select all that apply. a. Provide 5 to 6 small meals daily. b. Reposition the client from side to side every hour around the clock. c. Provide opportunities for the client to express concerns and verbalize feelings. d. Understand the side effects of furosemide e. Know the signs and symptoms of infection.

a, b, c

Which client outcomes are physiologic outcomes? Select all that apply. a. The client's hemoglobin A1c level is 7.4%. b. The client's blood pressure is 118/74 mm Hg. c. The client rates pain as a 6. d. The client self-administers insulin subcutaneously. e. The client describes manifestations of wound infection.

a, b, c

Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply. a. The UAP has sufficient knowledge and skill for completing the task. b. The nurse has clearly communicated instructions to the UAP. c. The UAP can verbalize what information to report to the nurse. d. The nurse seeks input from the UAP in planning the client's care for the shift. e. The UAP evaluates the client's response after implementing the task and then reports findings to the nurse.

a, b, c

Which parts of the nurse's decision about care occur after evaluating the client's responses to the plan of care? Select all that apply. a. Terminate the plan of care b. Modify the plan of care c. Continue the plan of care d. Begin the plan of care e. Communicate the plan of care

a, b, c

The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. What type of data should the nurse review prior to caring for this client? Select all that apply. a. Consultations b. Lab reports c. Medical history d. Progress notes e. Financial history f. X-ray reports

a, b, c, d, f

Which nursing qualities are helpful in winning the confidence of clients when first working with them? Select all that apply. a. Respect for client b. Competence c. Professionalism d. Number of years in profession e. Caring

a, b, c, e

Which examples of nursing actions involve direct care of the client? Select all that apply. a. A nurse counsels a young family who is interested in natural family planning. b. A nurse massages the back of a client while performing a skin assessment. c. A nurse arranges for a consultation for a client who has no health insurance. d. A nurse helps a client in hospice fill out a living will form. e. A nurse arranges for physical therapy for a client who had a stroke.

a, b, d

The nurse is interviewing an 80-year-old client admitted to the hospital for evaluation of diabetes. The client reports enjoying being in the hospital because the client lives alone and does not have many friends. The client reports having a spouse die 1 year ago and no longer being able to drive. The client relies on a daughter, who lives one hour away, to shop for the client once a week. The client states, "My daughter can never stay long and is just in and out in no time." Which nursing diagnoses would be appropriate for this client? Select all that apply. a. Risk for Loneliness b. Disturbed Body Image c. Powerlessness d. Chronic Low Self-esteem e. Impaired Memory

a, c

Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply. a. Record the client's intake and output. b. Assess the client's need for education. c. Assist the client to the bedside commode. d. Assess the client's risk for pressure injuries. e. Administer routine oral medications.

a, c

A client has returned to the clinic for a postoperative visit. The nurse reviews the plan of care and may choose to take which actions based on the client's previous responses to the current plan of care? Select all that apply. a. Terminate the plan of care if the client has achieved outcomes. b. Explain the plan of care to significant others and advise them of the expectation that the client will achieve outcomes within a reasonable amount of time. c. Modify the plan of care if the client has encountered difficulty with achieving outcomes. d. Continue the plan of care if more time could result in achievement of outcomes.

a, c, d

A nurse is developing the postoperative plan of care for a client admitted with a fractured hip who has undergone surgery to repair it. Which intervention would the nurse identify as a nurse-initiated intervention? Select all that apply. a. Assess the client's pain level every 2 hours. b. Administer prescribed opioid analgesic every 4 hours as needed. c. Turn the client every 2 hours per turning schedule. d. Teach the client how to perform relaxation as a pain relief strategy. e. Obtain complete blood count and chest x-ray in the morning.

a, c, d

A nurse on the unit fails to help a colleague ambulate a client even though there is time to do so. Which are appropriate responses by the nurse who required assistance with the client? Select all that apply. a. "We all have to work together as a team to provide quality care for our clients." b. "Never mind, I will get someone else to help." c. "This client is in need of our assistance, and everyone who is free should come together for improved client outcomes." d. "Please come and help and work together with me as a team." e. "If you don't assist me with client care, you may as well go home."

a, c, d

In which 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

a, c, d

Which items reflect the assessment phase of the nursing process? Select all that apply. a. The nurse asks the client, "How would you rate your pain?" b. The nurse assists the client with coughing and deep breathing every hour. c. The client's abdomen is firm and distended with hypoactive bowel sounds. d. The client states, "I rarely sleep more than 6 hours." e. The nurse and the client determine a tolerable pain level.

a, c, d

Which are correctly written client goals? 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 1700 today. d. The client will understand the side effects of digoxin. e. The client will eat at least 75% of all meals by May 5.

a, c, e

Which data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply. a. The client's chemotherapy causes nausea and loss of appetite. b. The client becomes teary when the client's daughter from out of state comes to the bedside. c. The client's ileostomy has produced 125 mL of effluent in the past four hours. d. The client is unwilling to manipulate or empty the ostomy bag. e. The client has been experiencing fatigue in recent weeks.

a, e

"The client will demonstrate cast care prior to discharge" is which type of evaluative statement? a. Cognitive b. Psychomotor c. Affective d. Physical changes

b

"The client will verbalize appropriate cast care on discharge" represents which type of outcome? a. Psychomotor b. Cognitive c. Affective d. Physical change

b

A client comes into the clinic for a routine postoperative visit. While the nurse is assessing the level of pain, the client states that there is occasional discomfort but that pain levels have improved daily since returning home from the hospital. What should the nurse's response be regarding the client's plan of care? a. Terminate the plan of care. b. Continue the plan of care. c. Promptly modify the plan of care. d. Suggest increasing the pain medication.

b

A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client? a. Head-to-toe b. Focused c. Emergency d. Time-lapse

b

A client comes to the health care provider's office reporting abdominal pain, for which the client has sought care before. Which type of assessment would the nurse perform? a. Initial b. Focused c. Emergency d. Time-lapse

b

A client has been discharged from an acute care facility with a referral for a home health nurse to make an assessment. What is the priority action by the home health nurse on the initial home visit? a. Care for the client's physical pain. b. Establish the client's database. c. Evaluate the care previously provided. d. Receive a report from the nursing staff.

b

A client has just given birth to the client's first baby. The client reports to the nurse not knowing very much about newborns because of limited exposure to them. Which is the priority nursing diagnosis for the nurse to address prior to discharge of this client? a. Fear b. Deficient Knowledge c. Alteration in Family Processes d. Stress Overload e. Ineffective Coping Mechanisms

b

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

b

A client is admitted to the hospital with an abscess on the leg that will not heal after multiple treatment options as an outpatient. The nurse knows from past experiences that the appearance of this type of wound in clients heavily suggests a resistant bacterial infection and the need for contact isolation and intravenous antibiotics. The nurse begins to prepare for this admission. What type of problem solving does this exhibit? a. Experiential b. Intuitive c. Scientific d. Trial-and-error

b

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis? a. Bronchial Pneumonia b. Ineffective Airway Clearance c. Acute Dyspnea d. Asthma Attack

b

A client is diagnosed with hypertension, placed on a low-sodium diet, and given smoking cessation literature. The nurse observes the client eating from a fast food restaraunt bag that a family member brought in and the client states, "I don't think I can do this." What is the nurse's first objective when implementing care for this client? a. Explain the effects of a high-salt diet and smoking on blood pressure. b. Identify what barriers the client feels are preventing adherence with the plan. c. Collaborate with other health care professionals about the client's treatment. d. Change the nursing care plan.

b

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." Which nursing action 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.

b

A client newly diagnosed with diabetes has been sent home after in-depth education regarding the diabetes management plan. Because the client is newly diagnosed, the nurse included in the plan of care a risk for unstable glucose. What is the most appropriate short-term outcome for this nursing diagnosis in the client? The client will: a. log all meals in a diary for the next 6 weeks. b. maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). c. maintain a normal HgbA1C. d. not exhibit signs and symptoms of hypoglycemia/hyperglycemia.

b

A nurse is caring for an older adult client in a long-term care facility and notices that the bed linens are damp when the client gets up in the morning. The nurse suspects that the client has been incontinent of urine and collects more data to form a conclusion. What type of problem has the nurse determined this is? a. Solvable problem b. Possible problem c. Critical problem d. Clinical problem

b

A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement? a. Adjust expected outcome to have client ambulate a shorter distance. b. Return the client to bed and provide pain relief measures. c. Ask the client to describe a personal walking goal. d. Review evidence-based interventions for the client's pain.

b

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem? a. Risk for Unstable Blood Glucose related to client's reluctance to manage the diabetic regimen b. Ineffective Health Maintenance related to client's denial of illness c. Risk for Injury related to client's mismanagement of disease d. Ineffective Coping related to client's inability to manage the diabetic regimen

b

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client? a. "It is extremely important to your health to strictly follow your plan of care." b. "It seems like you are having difficulty with your care regimen." c. "Should I arrange for a home health nurse to coordinate your care?" d. "Should I instruct your family to do the glucose checks for you?"

b

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem? a. Client will increase protein intake in small frequent meals. b. Client will alternate rest periods with exercise throughout the day. c. Client will use oxygen by nasal cannula when short of breath. d. Client will consistently perform pulmonary exercises.

b

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 b. Focused c. Time-lapse d. Emergency

b

A nurse caring for a client with a respiratory condition notices the client's breathing pattern is getting more irregular and the rate has greatly increased from 18 to 32 breaths per minute. The nurse notes that this client's vital signs are assessed once every shift, but believes the assessment should be done more frequently. Who is responsible for increasing the frequency of this client's assessments? a. The physician b. The nurse c. The case manager d. The nursing supervisor

b

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology? a. Fluid volume deficit b. Gastrointestinal upset from food poisoning c. Slow skin turgor d. Vomiting

b

A nurse identifies the following: "Impaired skin integrity related to immobility as evidenced by reddened areas on the sacrum." The nurse is most likely in which phase of the nursing process? a. Assessment b. Diagnosis c. Planning d. Implemenation

b

A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? a. Recognize that the nurse may be faced with this issue again and care for the client. b. Recognize the nurse's own limitations and ask for another nurse to be assigned. c. Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. d. Recognize the issue and care for the client to the best of the nurse's ability.

b

A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client? a. A full assessment of the urinary system b. A focused assessment of the specific problems identified c. Obtaining a detailed assessment of the client's sexual history d. Conducting a thorough systems review to validate data on the client's record

b

A nurse is caring for a client who has pneumonia. What is an appropriate nursing diagnosis? a. Impaired Respiration b. Ineffective Airway Clearance c. Altered Airway d. Infection (Pulmonary)

b

Which entry would be an example of appropriate documentation? a. Client appears depressed and tired. b. Client stated, "I am so down today, and I just don't have any energy." c. Client had a good bowel movement. d. Complains of abdominal pain. Probably constipated.

b

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? a. Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. b. Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. c. Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. d. Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.

b

A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process? a. Diagnosis b. Assessment c. Planning d. Implementation

b

A nurse is formulating a nursing diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client reports having flashbacks of the experience and fear of leaving the house alone. Which nursing diagnosis for this client is a NANDA-I-approved problem statement and correctly written? a. Psychological Overreaction related to being attacked b. Post-trauma Syndrome related to being attacked c. Needs Assistance coping with attack d. Mental Breakdown related to being attacked

b

A nurse is interviewing an asthmatic client who has a high respiratory rate and is having difficulty breathing. The client is consequently restless and can only speak a few words before pausing to catch a breath. What appropriate nursing diagnosis should the nurse document? a. Impaired Gas Exchange related to the disease condition b. Impaired Verbal Communication related to the breathing problem c. Inability to Speak due to ineffective airway clearance d. Impaired Physical Mobility related to tachypnea

b

A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first? a. Identify changes from the baseline. b. Determine the client's willingness to follow the regimen. c. Ensure physician approval for the education plan. d. Instruct the unlicensed assistive personnel on what to teach the client.

b

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 whether 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

A nurse is reviewing the plan of care for a client and notes: "The client will verbalize three signs of hypoglycemia to the staff accurately before discharge." The nurse should identify this statement as an example which element of nursing practice? a. Nursing diagnosis b. Outcome c. Intervention d. Evaluation

b

A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of: a. inconsistent cues. b. premature closure. c. clustering of cues. d. cluster interpretation.

b

A nurse overhears a coworker telling a somewhat offensive joke to a client. Which nursing action is indicated? a. Report what was overheard to the charge nurse. b. Discuss the occurrence with the coworker. c. Apologize to the client for the coworker's behavior. d. Investigate whether the coworker and client have a previous relationship.

b

A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has: a. an impaired cluster interpretation. b. a lack of cues, or premature closure. c. an ineffective database. d. an inaccurate evaluation.

b

After a client has a myocardial infarction, the nurse formulates a possible nursing diagnosis of "Powerlessness." To determine the accuracy of the diagnosis, what would be the nurse's most appropriate action? a. Determine the extent of cardiac tissue damage. b. Discuss the client's health condition with the client. c. Assess the client's knowledge of risk factors. d. Identify the client's support systems.

b

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? a. Health promotion b. Actual c. Risk d. Possible

b

After examining a child 2 years of age and based on findings, the nurse identifies a potential problem with normal growth and development. Which step of the nursing process does this identification of a potential problem represent? a. Assessing b. Diagnosing c. Planning d. Implementing

b

After incorrectly administering digoxin to a client, a nurse admits the error to the nurse manager and peers to prevent them from making the same mistake. This is an example of which approach to quality assurance? a. Quality by inspection b. Quality as opportunity c. Quality by supervision d. Quality as repetition

b

After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable? a. Developmental stage b. Psychosocial background c. Research findings d. Current standards

b

Before implementing any planned intervention, which action should the nurse take first? a. Have the required equipment ready for use. b. Reassess the client to determine whether the action is needed. c. Ask the client whether this is a good time to do the intervention. d. Record the planned intervention in the client's medical record.

b

During admission, a teenage client who has a diagnosis of anorexia informs the nurse of a 5-pound weight loss within the last 6 months. What should the nurse do with this data? a. Record it in the client's record. b. Validate the weight loss with the client. c. Inform the client that this cannot be correct. d. Ignore this information completely and continue collecting data.

b

During the interview component of the health assessment, how does the nurse convey to the client that the information is important? a. Nodding frequently during the interview b. Sitting at eye level with the client c. Standing next to the client while interviewing d. Limiting questions to those with yes or no answers

b

For the second time this week, a nurse reports to the nurse manager failing to perform an ordered dressing change due to a lack of time. The nurse manager recognizes that the nurse normally is very punctual and known to provide good care for clients and that the unit census has been very high this week. However, the nurse manager knows that quality care must be provided and reports this occurrence. Which approach to quality assurance does this scenario represent? a. Quality by inspection b. Quality as opportunity c. Quality by design d. Quality as promotion

b

Identifying the kind and amount of nursing services required is a possible solution for: a. clients who fail to communicate their needs. b. inadequate staffing. c. nurses who are bored. d. nurses frustrated with substandard care.

b

The charge nurse identifies the need for further education when a new nurse makes which statement? a. "Physical assessment is the examination of the client for objective data." b. "Physical assessment is the examination of the client for subjective data." c. "Physical assessment is ongoing to detect changes in the client's condition." d. "Physical assessment should be documented in a timely manner."

b

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? a. The client calls for assistance to get out of bed. b. The client is free of falls. c. The client is taught safety precautions. d. The client verbalizes risks for injury.

b

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 two-pack-per-day smoking habit. When developing the plan of care, what would be a priority nursing diagnosis for this client? a. Ineffective Health Maintenance as evidenced by smoking and unhealthy dietary habits b. Ineffective Airway Clearance related to tracheobronchial secretions as evidenced by expectorating thick, yellow secretions c. Ineffective Breathing Pattern related to client report of shortness of breath d. Ineffective Therapeutic Regimen Management due to smoking

b

The nurse is formulating nursing diagnoses pertaining to a client with pancreatic cancer. Which factors should the nurse identify as strengths of the client? Select all that apply. a. The client states that no one should ever ask for help from others. b. The client states a belief in a reward in heaven after death. c. The client has a long history of health problems. d. The client has been accompanied by family members to every appointment. e. The client has demonstrated effective coping skills in the past.

b, d, e

The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique? a. Begin using the technique to determine whether it is effective. b. Petition to change the protocol based on the new evidence. c. Ask the ER physician to order IM injections with the new technique. d. Research the protocols at other area emergency rooms.

b

The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate? a. "When I perform the nursing history, I will need to ask your family to leave the room." b. "I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes." c. "I will perform a physical assessment while I am obtaining the nursing history." d. "I will leave a form with you to complete the nursing history information I need."

b

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse? a. "You need to stop smoking for us to effectively combat this disease." b. "Please tell me your thoughts about treating this diagnosis." c. "Do you want to be discharged without treatment?" d. "What are your plans after discharge?"

b

The nurse caring for a client with obesity would like to address the possible health problems that can develop related to obesity. To plan care for this client, what type of nursing diagnosis would the nurse formulate? a. A problem-focused nursing diagnosis b. A risk nursing diagnosis c. A possible nursing diagnosis d. A health promotion nursing diagnosis

b

The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately states, "This client is getting worse." This is an example of the experienced nurse using: a. acute observation ability. b. intuitive problem identification. c. illogical thinking. d. an assumption to guide practice.

b

The nurse formulates the nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by client refuses to look at surgical site and client statement, "I'm ugly. My husband will no longer find me desirable." The decreased ability to cope with the removal of the breast is an example of: a. NANDA-I label. b. etiology. c. problem. d. defining characteristics.

b

The nurse is admitting a client who is unable to identify person, place, or time. To properly analyze these data, what action must the nurse take? a. Determine the client's medical diagnosis for clarification. b. Interview the client's family to assess the client's usual level of cognition. c. Assess the client's vital signs to determine the client's baseline. d. Ensure precautions are taken to prevent injury to the client.

b

The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment? a. Limit the assessment to objective data. b. Supplement the client's information by speaking with family or friends. c. Obtain the client's records from admissions to other institutions. d. Perform the assessment in several short episodes rather than at one sitting.

b

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? a. Registered nurse b. Nursing assistant c. A senior nursing student present for clinical d. Licensed practical nurse

b

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? a. Administer a prescribed medication to decrease the client's blood glucose level. b. Analyze the data and create an individualized nursing diagnosis. c. Follow up with the client later to determine whether the client's laboratory test results improve. d. Identify outcomes for the client with the client's input.

b

The nurse is caring for a client who underwent surgery 1 day ago. Which client problem can be addressed by independent nursing diagnoses? a. The client has a temperature of 101°F (38.3°C). b. The client has diminished breath sounds. c. The client has a blood pressure of 160/95 mm Hg. d. The client is requesting medication for pain.

b

The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action? a. Algorithm b. Standing orders c. Protocol d. Order set

b

The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan? a. Create a new nursing diagnosis to reflect new goals. b. Evaluate the use of current pain relief measures. c. Request a stronger analgesic from the provider. d. Provide additional relief with non-pharmacologic measures.

b

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning? a. Registered nurse b. Nursing assistant who is a nursing student c. A senior nursing student present for clinical d. Licensed practical nurse

b

The nurse is discussing dietary options with a client who is upset due to not being able to have foods the client previously enjoyed. The nurse states, "You may not be able to have steak, but you can have grilled salmon or grilled chicken. Which do you prefer?" What is the purpose for giving the client an option? a. To help the client adhere to the plan b. To give the client the opportunity to actively participate in care c. To save the client the trouble of looking in the menu d. To encourage the client to make a healthy food choice

b

The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next? a. Chart the data. b. Validate the data. c. Ignore the client's answer. d. Ignore the client's nonverbal behavior.

b

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority? a. Client will discuss drinking habits in therapy sessions the day after admission. b. By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms c. Client will commit to completing a 12-step program within 24 hours of admission. d. Within 3 days, client will be discharged.

b

The nurse recognizes that an example of a cognitive outcome is: a. The client demonstrates self-catheterization using clean technique by June 3. b. The client identifies three foods high in potassium by August 8. c. The client accurately measures the radial pulse for 1 minute by February 2. d. The client verbalizes increased confidence in testing glucose levels.

b

When assessing the firmness of a client's abdomen, the nurse should use which assessment technique? a. Inspection b. Palpation c. Percussion d. Auscultation

b

When caring for a client in the emergency room who has presented with symptoms of a myocardial infarction (MI), the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. For the nurse to be operating within the nurse's scope of practice, what conditions must be present? a. The nurse is using the standards of care for clients with MIs. b. The nurse is operating under standing orders for clients with suspected MIs. c. The nurse is experienced in the needs of clients with MIs. d. The nurse is ordering what the physician usually orders.

b

When using the nursing process, the nurse notes that there is a great deal of overlapping of the steps, with each step flowing into the next. What is the term for this characteristic of the nursing process? a. Interpersonal b. Dynamic c. Systematic d. Universally applicable

b

When writing an actual nursing diagnosis, the nurse includes the etiology that contributes to the current situation. This would be identified as: a. diagnostic label. b. related factors. c. defining characteristics. d. problem statement.

b

Which client outcome requires modification? a. Client will correctly self-administer subcutaneous insulin before discharge. b. By the end of instruction, client will know how to perform dressing changes. c. Client will demonstrate safe transfers from bed to chair within 24 hours. d. Within 2 days, client will describe two responses to firing of the internal defibrillator.

b

Which error has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity as evidenced by an open area with a 1-inch diameter on the right buttocks surrounded by a 1-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected. a. Wrote the diagnosis in terms of a need rather than a client response b. Reversed the health problem and the etiology c. Omitted the defining characteristics of the client health problem d. Identified environmental factors rather than client factors as the problem

b

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs? a. Seeking input from the client regarding preferences for a snack b. Cutting up food and opening drink containers for the client c. Providing the mother the phone number for the Poison Control Center d. Assisting the client to validate feelings regarding treatment options

b

Which is a psychomotor client goal? a. By 18AUG2015, the client will value health sufficiently to quit smoking. b. By 18AUG2015, the client will demonstrate improved motion in the left arm. c. By 18AUG15, the client will list three foods that are low in salt. d. By 18AUG2015, the client will learn three exercises designed to strengthen leg muscles.

b

Which nursing action would be most effective in helping a client learn self-care behaviors? a. Check with the client to ensure that personal self-care goals are being met. b. Model self-care behaviors for the client. c. Collect data on the number of self-care activities the client has performed that day. d. Ask client to discuss the client's goals for the day at the start of the shift.

b

Which nursing diagnosis has the priority when caring for an older adult client with Alzheimer disease? a. Impaired Physical Mobility b. Risk for Injury c. Self-Care Deficit d. Impaired Memory

b

Which nursing intervention is the most clear and well-written? a. The client will understand the importance of drinking adequate amounts of fluid. b. The nurse will offer the client 100 mL of water every 2 hours while the client is awake. c. The nurse will offer the client water when the client reports thirst. d. The client will continue to increase oral intake when awake.

b

Which question would be most helpful to the nurse in facilitating 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?"

b

Which statement made by the nurse indicates data that would be documented as part of an objective assessment? a. "The client's sister reports that the client has unrelieved pain." b. "The client's right leg is cold to the touch, from the knee to the foot." c. "The client reports nausea following eating." d. "The client reports having heartburn afterhear breakfast."

b

Which step in the nursing process is most closely associated with cognitively skilled nurses? a. Assessing b. Planning c. Implementing d. Evaluating

b

Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy? a. Initial b. Focused c. Emergency d. Time-lapse

b

While caring for a client admitted with a Clostridium difficile infection, the nurse notes that the client has had three loose bowel movements in 3 hours. What would be the most appropriate nursing diagnosis to address this health problem? a. Risk for Infection Transmission related to high potential for communicability b. Diarrhea related to infectious processes secondary to C. difficile infection as evidenced by three loose bowel movements in 3 hours c. Fluid Volume Excess related to diarrhea as evidenced by three loose bowel movements in 3 hours d. Risk for Injury related to urgent need for bowel evacuation

b

While caring for a client recovering from a cerebrovascular accident, the nurse determines that the client would benefit from the services of physical therapy. How should the nurse plan to involve physical therapy in the client's care? a. By formulating an actual nursing diagnosis b. By formulating a collaborative problem c. By formulating a medical diagnosis d. By formulating orders for physical therapy

b

A nurse is caring for a client admitted for bowel obstruction, which now has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply. a. Allow the client to order favorite foods from the hospital menu. b. Auscultate for bowel sounds. c. Begin feedings with clear broth. d. Consult with a dietitian regarding appropriate foods.

b, c, d

Which situations observed by a nurse should the nurse report to the nurse manager for quality assurance? Select all that apply. a. A nurse cleans a stethoscope between clients. b. A nurse assesses a client after sneezing into the nurse's hands. c. A nurse administers medications to the wrong client. d. A nurse delays answering call lights to an abusive client. e. A nurse refuses to provide care to a client with HIV.

b, c, d, e

A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply. a. The client states, "I miss my wife every day." b. The client no longer indulges in usual activities. c. The client attempted suicide 1 month ago. d. The client keeps a picture of the client's wife at the bedside. e. The client states, "I have no interest in doing anything."

b, c, e

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply. a. Initial assessment of the mother after birth of the infant b. Assisting the client with personal hygiene needs and ambulation c. Assisting and teaching the client to breastfeed the infant d. Providing routine discharge instructions related to infant care e. Transporting the infant to the mother's room according to hospital policy

b, e

A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention? a. Surveillance b. Supportive c. Coordinating d. Technical

c

A client who is scheduled for coronary angioplasty is concerned about whether the surgery is safe and wonders whether it would be beneficial. Which nursing diagnosis relates to this client's condition? a. Ineffective Coping related to anxiety and fear of surgery b. Anxiety related to fear of death during surgery c. Fear related to potential risk and surgical outcomes d. Knowledge Deficit: treatment regimen related to surgical outcomes

c

A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking." What is the priority nursing diagnosis? a. Impaired Walking b. Activity Intolerance c. Deficient Diversional Activity d. Disturbed Body Image

c

A new mother is having difficulty breastfeeding a newborn infant. A goal was established stating that the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding. The nurse evaluates the original goal as: a. met. b. partially met. c. completely unmet. d. inappropriately chosen for this client.

c

A nurse administers colchicine according to the standardized plan of care for a client admitted with acute gouty arthritis of the right great toe. Which assessment information deviates from the expected client outcome for the first 12 hours and requires nursing intervention? a. Uric acid level decreases. b. Client walks to the bathroom. c. Foot remains red and swollen. d. Client reports diarrhea.

c

A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered? a. Initial planning b. Comprehensive planning c. Ongoing planning d. Discharge planning

c

A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan? a. Restrict intake of foods and fluids. b. Monitor for noncompliance. c. Monitor for lactic acidosis d. Administer B12 injections

c

A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which documented statement best represents the data that should be collected in a nursing assessment? a. Neurologic examination reveals partial paralysis and aphasic speech. b. Brain scan shows evidence of a clot in the middle cerebral artery. c. Client is unable to communicate basic needs and cannot perform hygiene measures with left hand. d. Left-sided weakness and speech deficit indicate probable stroke.

c

A nurse is assisting with feeding residents 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 cardiopulmonary resuscitation. Why did the nurse assess respiratory status? a. To establish a database for medical care b. To practice respiratory assessment skills c. To identify a life-threatening problem d. To facilitate the resident's ability to breathe

c

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records? a. Ineffective Movement related to arthritis b. Impaired Movements due to pain c. Impaired Physical Mobility related to pain d. Ineffective Physical Mobility due to pain

c

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining? a. Process b. Structure c. Outcome d. Cost-effectiveness

c

A nurse is evaluating an established plan of care. After identifying the evaluative criteria and standards (expected patient outcomes), what must the nurse do next? a. Interpret and summarize findings. b. Document the nurse's judgment. c. Collect data about client responses. d. Formulate a new plan of care.

c

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information? a. If the client is in bed, the nurse stands at the foot of the bed. b. If both the nurse and client are seated, their chairs are at right angles to each other, 30 cm apart. c. If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. d. If the client is in bed, the nurse stands at the side of the bed.

c

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action? a. Verbally report the finding to the charge nurse at the change of shift. b. Inform the unlicensed assistive personnel to document the finding. c. Verbally report the finding immediately to the client's physician. d. Reassess the client's temperature in 2 hours and chart this data.

c

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: a. agrees with each of the client's statements. b. attempts to write down everything the client says. c. uses broad, open statements to communicate with the client. d. reassures the client of good outcomes.

c

A nurse writes down the following outcome for a depressed client: "By 6/9/20, the client will state three positive benefits of receiving counseling." This is an example of which type of outcome? a. Psychomotor b. Cognitive c. Affective d. Realistic

c

A plan of care for a client with a low potassium level includes providing information about the effect of medications and about dietary intake of foods high in potassium. How would a nurse measure achievement of an outcome for this plan? a. Physical assessment b. Health history c. Laboratory data d. Client statements

c

An older adult client has lost significant muscle mass during recovery from a systemic infection. As a result, the client has made no progress toward meeting any of the outcomes for mobility and activities of daily living that are specified in the nursing plan of care. How should the nurse best respond to this situation? a. Continue the current plan of care with the hope that the client will achieve the outcomes. b. Terminate the plan of care because it does not now 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.

c

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should: a. review literature pertinent to the client's attributes. b. assess personal feelings regarding similar clinical situations. c. inform the client of the maintenance of confidentiality. d. implement supportive nursing interventions.

c

Nurses understand the problem that clients have when they are repeatedly asked the same questions. To best avoid this problem, which intervention should nurses perform when beginning to collect assessment data? a. Organize all questions into categories. b. Make the questions short. c. Carefully review the client's record. d. Tell the client the questions will be quick.

c

The client is being seen in an outpatient clinic. The client reports experiencing vomiting and diarrhea for several days. The nurse completes the assessment and advises the client to drink an oral electrolyte solution. Which type of problem solving has the nurse used? a. Creative thinking b. Trial-and-error c. Scientific d. Intuitive

c

The client outcome, "The mother will express confidence in being able to meet nutritional needs of the infant," is an example of which type of outcome statement? a. Psychomotor b. Cognitive c. Affective d. Physical

c

The client reports right knee pain of 6/10 on the pain scale and requests medication. The nurse assesses and flushes the intravenous site. Which type of intervention skill is the nurse using? a. Interpersonal skill b. Intellectual skill c. Technical skill d. Mechanical skill

c

The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response? a. "I will report your concerns to the nurse manager." b. "I will discuss your concerns with the night nurse." c. "You should always speak up if you have any questions about your care." d. "You always have the right to refuse any medication or treatment."

c

The health care team has convened to discuss the care of an end-of-life client who is not able to achieve an acceptable level of comfort. The physician asks for the nurse's perspective of the situation. Which standard for establishing and sustaining healthy work environments does this action represent? a. Skilled communication b. Effective decision making c. True collaboration d. Appropriate staffing

c

The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's long-term safety? a. Remove all the cluttered objects from the pathway to the client's bathroom. b. Instruct the client about the need to keep the walkway to the bathroom clear. c. Assist the client to identify strategies to promote safety in the home. d. Assign a home health aide to perform housekeeping duties.

c

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. The nurse expressed the client outcomes as a nursing intervention. b. The nurse wrote vague outcomes that will confuse other nurses. c. The nurse included more than one client behavior in the outcome. d. The nurse used verbs that are not observable and measurable.

c

The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of being pregnant. What assessment data would be appropriate to lead the nurse to select this diagnosis? a. The client states, "I am shocked to find out that I am pregnant." b. The client states, "I do not plan to tell my family about my pregnancy right away." c. The client states, "I do not know how to take care of a baby." d. The client states, "I know that I will have to make some changes in my life."

c

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? a. Continue the education and remind the client that it is essential to learn self-care. b. Medicate the client for anxiety and continue the education later. c. Discontinue the education and attempt at another time. d. Discontinue the education and ask the client for permission to teach a family member.

c

The nurse is assessing the client's behavioral response to a nursing intervention. This type of evaluation is known as: a. structural evaluation. b. behavior modification. c. outcome evaluation. d. process evaluation.

c

The nurse is attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. What interpersonal skill is the nurse displaying? a. Developing technical skills b. Enjoying the rewards of mutual interchange c. Developing accountability d. Developing ethical/legal skills

c

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client? a. Risk for Loneliness b. Acute Pain c. Risk for Impaired Parenting d. Ineffective Breastfeeding e. Ineffective Infant Feeding Pattern

c

The nurse is caring for a client who is experiencing a collaborative problem. The nurse should plan the client's care based on an understanding that this problem is characterized by: a. an emergent condition that requires rapid nursing response. b. a risk or wellness human response to health problems. c. a result of disease, trauma, treatment, or diagnostic studies. d. a convenient means for communication among team members.

c

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next? a. Develop an additional nursing diagnosis to meet the client's health needs. b. Change the nursing diagnosis because the client's problem was falsely identified. c. Modify the plan of care and interventions to meet the client's needs. d. Reassess the client for more symptoms of deficient fluid volume.

c

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond? a. Review with the client the risks and benefits of surgery. b. Ask the client to discuss the decision with family members. c. Discuss with the client the reasons for declining surgery. d. Notify the physician of the client's refusal.

c

The nurse is preparing to document the nursing diagnoses for a client. What is the most appropriate outcome for the nursing diagnosis of impaired gas exchange? a. The client will have clear breath sounds. b. The client will have decreased work of breathing. c. The client will maintain a pulse oximeter reading of greater than 94% (0.94 L). d. The client will maintain a respiratory rate between 12 and 20 breaths per minute.

c

The nurse is reviewing information about a client and notes the following documentation: "Client is confused." The nurse recognizes that this information is an example of: a. subjective data. b. a data cue. c. an inference. d. primary data.

c

The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which should the nurse recognize as an example of outcome evaluation? a. A 4% increase in the number of baccalaureate-prepared nurses employed in the facility b. Bed occupancy rates of 97% in the critical care areas and 92% in the non-critical care areas c. A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery d. A rate of 98% of clients admitted to the hospital who had a nursing history completed within 24 hours after admission

c

The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform? a. Take the vital signs of the client who just returned from surgery. b. Feed a client who is eating for the first time following an ischemic stroke. c. Bathe a client with stable angina who has a continuous IV infusing. d. Assist the client who is ambulating the first time since hip replacement surgery.

c

The nursing staff on one team in a long-term care facility often plays loud rock music on the radio for residents to listen to in the common areas. The staff also organizes children's games as a form of physical and recreational therapy. What is the staff doing in these situations? a. The staff is considering the hearing level of older adults by playing loud music. b. The staff is failing to consider visual deficits that occur when a person ages. c. The staff is ignoring the developmental needs of the older adults in the facility. d. The staff is meeting the clients' needs for sensory input.

c

What result is the most appropriate outcome for the nursing diagnosis of Impaired Urinary Elimination? The client will: a. feel the urge to urinate. b. have clear yellow urine. c. maintain urine output of 30 mL/hr. d. urinate three times per day.

c

What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall? a. Assess cholesterol levels. b. Obtain an electrocardiogram daily. c. Assess blood pressure with a large cuff. d. Begin client education regarding a low-fat diet.

c

When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make? a. The nurse should assess the client's dietary habits. b. The nurse should assess the client's bowel sounds. c. The nurse should determine the client's normal bowel elimination pattern. d. The nurse should determine the standard bowel elimination pattern for the client's age.

c

When the nurse is administering medication, an older adult client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client? a. "It is a habit that nurses develop in school." b. "It is a hospital policy to reduce the potential for errors." c. "We ask your name to ensure that we are treating the right client." d. "We ask your name to show that we respect your rights."

c

Which action is a priority role of the nurse when caring for a client with collaborative problems? a. Assessing the client's understanding of risk factors b. Resolving health issues through independent nursing measures c. Reporting trends that suggest the development of complications d. Managing an emerging problem with the help of another registered nurse

c

Which action 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 health care. d. Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

c

Which action should the nurse associate with outcome identification and planning in the nursing process? a. Decides whether to continue, modify, or terminate nursing care b. Develops a prioritized list of nursing diagnoses c. Develops an individualized plan of nursing care d. Determines the client's health status, self-care ability, and need for nursing

c

Which action would be inappropriate for the nurse to perform when implementing a client's plan of care? a. Ask the client, who speaks the dominant language as a second language, to state in one's own words what it means to be NPO. b. Seek input from the family on how the client with aphasia normally communicates at home. c. Respond to the postoperative client's question by stating that baths are given only in the morning. d. Request that family members provide ethnic or cultural foods of the client's liking.

c

Which action would the nurse perform in the assessment phase of the nursing process? a. Developing a plan to manage the client's health problems b. Coming up with a nursing diagnosis based on a potential health risk c. Asking the client whether the client has cultural preferences d. Determining whether the client's goals for wellness have been met

c

Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer? a. By the next clinic visit, the client will report needing antiemetic medication. b. After attending a cancer support group, the client will report being in a good mood. c. By discharge, the client will perform hand hygiene before and after port care. d. The client will schedule radiation therapy sessions and plan for chemotherapy.

c

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

c

Which nurse is using criteria to determine expected standards of performance? a. The nurse manager provides the staff nurse feedback regarding job performance for the previous year. b. The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. c. The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. d. The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.

c

Which outcome illustrates a common error nurses make when writing client outcomes? a. Client will drink 100 mL of fluid every 2 hours from 0600 to 2100. 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.

c

Which outcome 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.

c

Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist? a. Medical history b. Progress notes c. Consultation d. Laboratory reports

c

Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training? a. Validation is an important part of assessment. b. Validation helps to keep data as free from error as possible. c. All data collected need to be validated. d. Validation is the act of confirming or verifying.

c

Which statement by a nurse best indicates an accurate understanding of the different types of assessments? a. "It is up to the nurse to decide which assessment to perform." b. "How much time the nurse has and how the client is feeling determine which type of assessment to perform." c. "The purpose for the assessment offers guidance for which type and how much data to collect." d. "The physician informs the nurse of which type of assessment to perform for each client."

c

Which statement on a plan of care should a nurse identify as a nursing intervention? a. The client self-administered insulin correctly following education. b. The client will correctly demonstrate deep-breathing exercises after education. c. Perform range-of-motion exercises to all of the client's joints each morning. d. Readiness for Enhanced Communication

c

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? a. Secure the client's jewelry before surgery. b. Reassess the client's sacrum for redness when doing a bed bath. c. Provide the client with assistance in transferring to the bedside commode. d. Retrieve a unit of blood from the blood bank.

c

While performing the nursing history, the nurse notes that the client reports having very little pain but is occasionally grimacing and rubbing one shoulder throughout the interview. The nurse acknowledges this behavior, questions the client, and then proceeds with other phases of the interview. This action takes place during which phase of the nursing interview? a. Preparatory b. Introductory c. Maintenance d. Concluding

c

Which client outcomes are psychomotor outcomes? Select all that apply. a. The client identifies five low-sodium foods. b. The client describes how to empty a Jackson-Pratt drain. c. The client measures capillary blood glucose level. d. The client self-catheterizes using clean technique. e. The client reports imagery is effective in controlling anxiety.

c, d

A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply. a. Heart failure b. Pneumonia c. Impaired mobility d. Imbalanced nutrition e. Ineffective coping

c, d, e

Which statements are true about informatics in nursing practice? Select all that apply. a. Computers do not help with communication, but deter it because of the lack of personal interaction. b. Informatics only involves documentation of timely and accurate charting. c. Nurses should value technologies that support error prevention and care coordination. d. The use of informatics can help manage knowledge and mitigate error. e. Utilization of information services helps to support decision making.

c, d, e

A client has been admitted to a hospital due to an acute psychotic episode. Which assessment data would the nurse identify as this client's strengths? Select all that apply. a. The client has been living on the street for 3 weeks. b. The client is male and 35 years old. c. The client has ample financial resources. d. The client refuses to take the ordered medication. e. The client is willing to attend counseling sessions.

c, e

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. a. The client is male. b. The client is married. c. The client is blind. d. The client is an architect. e. The client denies the need for education.

c, e

The nurse is caring for a client who does not speak the same language. The unlicensed assistive personnel (UAP) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Select all that apply. a. Interview the client as part of the admission assessment. b. Provide education to the client, including discharge instructions. c. Ask the client questions regarding personal care needs. d. Demonstrate and teach new caregiving procedures to the family. e. Counsel the client about making adjustments to a new medical condition. f. Orient the client and family to the room, including the call light button.

c, f

A client is a poor historian of the client's past medical history. Whom should the nurse consult about the client's past history? a. Physician b. Old chart c. Social worker d. Family

d

A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client? a. Insomnia b. Fatigue c. Agitated Movement d. Ineffective Impulse Control

d

A client who was admitted to the acute care unit with angina pectoris is no longer having chest pain. Based on this assessment, what does the nurse decide to do with the plan of care for chest pain? a. Establish a new plan of care. b. Keep the diagnosis of chest pain since it could occur again to prevent rewriting it. c. Continue the current plan of care since it is already complete. d. Terminate the plan of care related to the nursing diagnosis of chest pain.

d

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

A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a physician is termed: a. protocols. b. nursing interventions. c. collaborative orders. d. standing orders.

d

A nurse has been providing discharge teaching to a client with type 1 diabetes. Which outcome indicates that the teaching has been effective? a. Before discharge, the client will attempt to administer a subcutaneous injection. b. By a certain date, the client will talk to a dietitian regarding information for a diabetic diet. c. Before discharge, the client will understand proper foot care and eye care. d. By a certain date, the client will verbalize signs and symptoms of hypoglycemia.

d

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which statement represents objective data the nurse is likely to gather and document during this assessment? a. "My leg hurts so bad. I can't stand it." b. "I feel anxious and frightened." c. "I am so sick; I am about to throw up." d. "Unable to palpate femoral pulse in left leg."

d

A nurse is evaluating nursing care and client outcomes by using a retrospective evaluation. Which action would the nurse perform in this approach? a. The nurse directly observes the nursing care being provided. b. The nurse reviews the client chart while the client is being cared for. c. The nurse interviews the client while the client is receiving the care. d. The nurse devises a postdischarge questionnaire to evaluate client satisfaction.

d

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

d

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select? a. Ineffective Airway Clearance related to bronchial constriction b. Noncompliance related to deficient knowledge of a new medical diagnosis. c. Anticipatory Grieving related to chronic illness management d. Knowledge Deficit: Medications related to new medical diagnosis

d

A nurse is working with a group of staff members to address the needs of a client as they develop the client's interdisciplinary plan of care. Which question if asked by the nurse addresses the standard of breadth when judging the group's thinking? a. "Could you elaborate on that point a bit more?" b. "How could we find out whether that is true?" c. "Could you be more specific in your observations?" d. "Is there another way to look at this situation?"

d

A nurse manager identifies a need for further instruction when a new nurse makes which statement? a. "Caregivers can be a helpful source of data when the client has a limited capacity for information." b. "Family members are a good source of data when the client is a young child." c. "The client is usually the best source for collecting data." d. "The client is always the best source for collecting data."

d

A nursing diagnosis is written as Disturbed Body Image related to presence of large scar over left side of face. What does the phrase "Disturbed Body Image" 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

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate? a. An problem-focused nursing diagnosis b. A risk nursing diagnosis c. A possible nursing diagnosis d. A health promotion nursing diagnosis

d

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 by the nurse to the client would be best to validate this client problem? a. "I have assessed you and find that you are fatigued." b. "I have analyzed your information and interpret it to mean that you are fatigued." c. "Why are you so tired all the time?" d. "I think fatigue is a problem for you. Do you agree?"

d

During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficent data for planning care. Which action by the nurse would be most appropriate in this situation? a. Ask the client to wake up and try to answer the interview questions. b. Ask the client's spouse to come in and answer the interview questions. c. Wait until the next day to obtain the answers to the interview questions. d. Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.

d

For a client with a self-care deficit, the long-term goal is that the client will be able to dress oneself by the end of the 6-week therapy. For best results, when should the nurse evaluate the client's progress toward this goal? a. When the client is discharged b. At the end of the 6-week therapy c. Only when the client shows some progress d. As soon as possible

d

The charge nurse overhears two nurses talking about nursing interventions. Which statement by one of the nurses indicates that 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

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of: a. an affective outcome. b. a psychomotor outcome. c. a physiologic outcome d. a cognitive outcome

d

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case? a. Performing an abdominal assessment b. Asking the client to discuss social functioning c. Interviewing friends to ascertain the client's exercise habits d. Obtaining data regarding the amount and frequency of drinkingd

d

The client's expected outcome is "The client will maintain skin integrity by discharge." Which measure is best in evaluating the outcome? a. The client's ability to reposition self in bed b. The presence of a pressure-relieving mattress on the bed c. The percent intake of a diet high in protein d. The condition of the skin over bony prominences

d

The expected outcome for a client with a new diagnosis of rheumatoid arthritis (RA) is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met? a. "I will take the medications until the inflammation goes away." b. "I will take my medications on an empty stomach for maximum effect." c. "I should increase water intake if I have dark bowel movements." d. "I should call my health care provider if I have a sore that won't heal."

d

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

d

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 with baseline data d. To establish a database to identify problems and strengths

d

The nurse is assessing a client in an outpatient setting. The client states,"I don't want to live anymore. My family hates me, and I am so tired of being sick. I have a gun, and I am seriously thinking of killing myself." The client reports a 30-year heavy smoking habit and having a cough for about 6 months. Auscultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminished bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing diagnosis for this client? a. Risk-Prone Health Behavior b. Ineffective Health Maintenance c. Impaired Gas Exchange d. Risk for Suicide e. Stress Overload

d

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next? a. Cover the infant. b. Ask the parent whether the child has been exposed to cold temperatures. c. Assess the skin for signs of cyanosis. d. Recheck the temperature, paying close attention to technique.

d

The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next? a. Recheck the client's pulse in 2 hours. b. Recheck the client's pulse at the next scheduled assessment time and document the findings on the chart. c. Document the findings on the chart and recheck in 1 hour. d. Notify the physician of the change and document the finding. e. Notify the physician after the next scheduled assessment time if the pulse is unchanged.

d

The nurse is caring for a pediatric client with respiratory distress. Upon assessment the client has increased respirations and work of breathing (WOB). Breath sounds are adventitious and the client has thick yellow/green drainage coming from the nose. Based on these findings, the nurse determines that this client has an ineffective airway clearance related to copious amounts of thick secretions and proceeds to perform nasopharyngeal suctioning to relieve some of the secretions. If the nurse were documenting the evaluation of this intervention, what would be documented? a. Increased respirations, increased WOB, adventitious breath sounds, thick nasal secretions b. Ineffective airway clearance related to copious amounts of thick secretions c. Nasopharyngeal suctioning d. The amount and type of drainage suctioned from the nares, and the client's response

d

The nurse maintains a journal in which to reflect on the nurse's clinical practice. Which entry is an example of reflection for action? a. "The client's son reported to me that the client needed medication for postoperative pain." b. "It has been over 4 hours since I have medicated the client for pain." c. "I obtained the medication. When I got to the room, the client was sleeping. I refused to give the medication." d. "Next time I will assess the client before obtaining the medication."

d

The nurse participates in a quality assurance program and reviews evaluation data for the previous month. The data indicates a nursing plan was developed within 8 hours of admission for 97% of all admissions. The nurse recognizes this as which type of evaluation? a. Design evaluation b. Outcome evaluation c. Structure evaluation d. Process evaluation

d

The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate? a. "Nursing interventions are selected based on the etiology in the nursing diagnosis and must be compatible with other therapies planned for the client." b. "The client's developmental level, values, beliefs, and cultural and psychosocial background should be considered when selecting nursing interventions." c. "Nursing interventions should be consistent with standards of nursing care and research findings." d. "Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

d

Which action by the nurse is an example of peer review? a. The nurse seeks feedback from the nurse manager regarding job performance for the previous year. b. The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. c. The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. d. The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.

d

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training? a. The nurse sits on eye level with the client. b. The nurse verifies the client's name. c. The nurse asks the client what name the client would like to be called. d. The nurse introduces onself to the client by pointing to the nurse's name badge. e. The nurse should sit on eye level with the client.

d

Which action is appropriate when evaluating a client's responses to a plan of care? a. Reinforce the plan of care when each expected outcome is achieved. b. Terminate the plan if there are difficulties achieving the goals/outcomes. c. Terminate the plan of care upon client discharge. d. Continue the plan of care if more time is needed to achieve the goals/outcomes.

d

Which error has the nurse made in formulating the nursing diagnosis: Pain related to nurse failing to administer pain med in a timely manner as evidenced by client pain rating of 7 out of 10, client guarding abdominal incision, client ambulating slowly? a. Used imprecise language b. Used a medical diagnosis c. Omitted defining characteristics d. Used legally inadvisable terms

d

Which interpersonal skill is essential to the practice of nursing? a. Performing technical skills knowledgeably and safely b. Maintaining emotional distance from clients and families c. Keeping personal information among shared clients confidential d. Promoting the dignity and respect of clients as people

d

Which is an accurately phrased risk nursing diagnosis? a. Risk for Impaired Coping as evidenced by client crying b. Risk for Fluid Volume Excess related to increased oral intake as evidenced by consuming 3 L of soda c. Risk for Pain After Surgery d. Risk for Falls related to altered mobility

d

Which nursing diagnosis is written incorrectly as a result of the health problem and etiology being reversed? a. Pain related to tissue trauma and inflammation b. Risk for Injury related to lack of knowledge of crutch walking c. Risk for Disturbed Body Image related to decreased ability to cope with surgical removal of right breast d. Prolonged Immobility related to impaired skin integrity

d

Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight? a. Anorexia Nervosa b. Lack of Adequate Nutrition c. Weight Loss d. Imbalanced Nutrition: Less than Body Requirements

d

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? a. Educational b. Psychomotor c. Maintenance d. Surveillance

d

These nursing diagnoses appear on a client's care plan. In what order will the nurse prioritize them? a. Altered Body Image b. Fluid Volume Deficit c. Risk for Impaired Skin Integrity d. Impaired Swallowing

d, b, c, a