N320 Prep U questions

A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing?

focused

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?

health promotion nursing diagnosis

The primary purpose of nursing implementation is to:

help the client achieve optimal levels of health.

The nurse researcher is aware that the type of variable that can be manipulated in a study is which type of variable?

independent

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

individualize the plan to the client

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?

ineffective airway clearance

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?

ineffective breastfeeding

An older adult client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. The client is tearful and reports feeling lonely and abandoned in the hospital unit. The family visits daily, and flowers and cards are in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Which nursing diagnosis and outcome criteria need to be addressed immediately for this client?

ineffective coping; verbalizes support systems

A nurse is providing care to a client who is feeling lonely and isolated. In an effort to develop a trusting nurse-client relationship, the nurse exhibits a caring attitude, ensures the client's privacy, and spends time with the client to promote therapeutic communication. The nurse is meeting which category of client needs?

love and belonging

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:

maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L).

The community environment affects the well-being of the individual and the family. Which is the health responsibility of the family?

maintain a healthy lifestyle

What result is the most appropriate outcome for the nursing diagnosis of Impaired Urinary Elimination? The client will:

maintain urine output of 30 mL/hr.

All of the activities listed are related to evaluation, but which activity is the priority concern for nurses?

meeting the care needs of client

A nurse is planning to conduct a nursing research study and is seeking federal funding. Which institution would be most helpful for the nurse to contact regarding acquiring funding?

national institute of nursing research

The nursing staff on a hospital unit uses peer review to improve professional performance. Who performs the review?

nurses

A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care?

nursing process

When caring for a psychiatric client, a nurse would make a formal contract with the client during which phase of the nurse-client relationship?

orientation phase

The focus of nursing is always on which of the four common concepts in nursing theory?

person

A nurse researcher is studying female clients who have survived breast cancer. The nurse asks each client to describe her experience and then analyzes the data for the meaning of the experience within each person's own reality. This nurse has used what type of qualitative research method?

phenomenology

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?

physical changes

Prior to the first visit following gastrectomy, the client will have a weight loss of 10 lb (4.5 kg). This is an example of which type of evaluative statement?

physical changes

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?

quality as opportunity

The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted?

quality assurance

A nurse researcher must decide on the method for conducting the research. The researcher that plans to emphasize collection of numerical data and analysis would select which method of research?

quantitative research

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?

reflection

Self-evaluation is a method that nurses use to promote their own development and to grow in confidence in their nursing roles. This process is referred to as:

reflective practice

The primary purpose for evaluating data about a client's care according to a functional health approach is to:

revise or modify the client care plan.

A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage?

risk of self-harm

The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs?

safety and security

The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual?

sociocultural dimension

The nurse is caring for a client who ascribes to the theory of animism. When attempting to explain this theory to other staff members, the nurse should state:

"Everything in nature is alive with invisible forces."

The nurse is attempting to provide anticipatory guidance for the parents of an 18-month-old child. Which statement would be best for the nurse to make?

"Keep all medications in a locked cabinet."

Which activity is the clearest example of the evaluation step in the nursing process?

Checking the client's blood pressure 30 minutes after administering captopril

During the course of any given day of work in the acute care setting, the nurse may need to perform which roles? Select all that apply.

Communicator, Counselor, Teacher

The nurse is performing an extensive dressing change on a client with burns. The nurse explains each step as it is being performed. The nurse is acting in which role by providing explanation of each step?

Educator

In the role of entrepreneur, the nurse's primary responsibility is:

Managing a health-related business

The nurse going back to school for nurse midwifery can trace education for nurse midwifery to which nursing leader?

Mary Brekinridge

For the nurse become a nurse practitioner, what is the minimal degree the nurse will need to acquire?

Master's

The nursing process includes step(s)? Select all that apply

Plan, assess, implement, evaluate

Which nursing intervention would be most appropriate for a new mother that calls the nursery for help with breastfeeding?

Refer the mother for a home care visit

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?

Show respect for the client, and engage in open communication in getting to know the client.

Which explanation accurately differentiates the role of the registered nurse (RN) from that of the licensed practical/vocational nurse (LPN/LVN)?

The LPN/LVN should work under the supervision of an RN.

The registered nurse communicates with the physical therapist that a client is now on strict bed rest due to bradycardia. Which statement best explains the standard exemplified by the nurse?

The RN coordinates care delivery.

Which action by the nurse demonstrates the nurse's efforts to meet the client's self-actualization needs?

The nurse arranges for the client's clergy to visit after visiting hours.

Which statement is true regarding Friedman's theory of family-centered nursing care?

The role of the family is essential in every level of nursing practice

The nurse is caring for a client after a stroke rendered the client's right side weaker than the left. The nurse coordinates the plan of care with the physical therapist. The nurse's interventions reflect which one of nursing's four broad goals?

To restore health

A Spanish-speaking client is admitted to the emergency department with a urinary tract infection and is experiencing a stress response from hospitalization. What is the priority nursing intervention?

contact a translator

The primary aim of the Healthy People 2030 initiative is:

health promotion

Which theory describes, explains, predicts, and controls outcomes in nursing practice?

nursing theory

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:

outcome

The nurse conducts a home safety assessment for a client. Which statement best explains the standard of care being implemented?

The RN promotes a safe environment

The need for university-based nursing education programs was brought to light during which important historical time?

World War II

An adolescent confides in the school nurse that the adolescent is arguing daily with her mother and often wonders whether her mother loves her. The school nurse recognizes that the student faces which of the following risk factors for altered family health?

a psychosocial risk factor

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?

activity and rest

The home health nurse is making an initial visit to a client's home. During the visit the nurse observes the mother cooking dinner, the father watching television with a child on the lap, and the grandmother in a rocking chair reading the Bible. The nurse recognizes this family structure as which of the following?

extended family

Which action should the nurse implement when working with a medically homeless client?

Encourage client to utilize the free health care clinic.

The RN is working with hospital administrators to transform care at their facility. Which nursing competency will be critical for the nurse to utilize?

Work effectively in interdisciplinary teams

A registered nurse (RN) is caring for four clients on a medical-surgical unit. Which task is most appropriate for the nurse to delegate to the licensed practical nurse (LPN)?

administering bedside blood glucose testing

A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client?

prioritize the nursing diagnoses

What type of research study would a hospital conduct to explore clients' and families' perceptions of receiving care?

qualitative

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:

intuitive problem identification

What was one barrier to the development of the nursing profession in the United States after the Civil War?

lack of educational standards

A prospective nursing student desires a career that will allow the opportunity to provide client care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student?

licensed or vocational nursing program

The nurse is creating a plan of care for a client. Which actions by the nurse demonstrate the components of the nursing process? Select all that apply.

Identifies the needs of the client, Evaluates the effectiveness of the plan of care, Plans interventions to meet the client's health care needs

Which statement regarding critical thinking in nursing is true?

It is a systematic way of thinking.

A nurse educator is discussing the role of nursing based on the American Nurses Association (ANA). Which statement best describes this role?

It is the role of nursing to provide a caring relationship that facilitates health and healing.

A nurse identifies a client's health care needs and devises a plan of care to meet those needs. Which guideline is being followed in this case?

Nursing process

Which scenario is the best example of a nurse in the role of counselor?

A nurse allowing a crying client to verbalize fears of death

What is the most beneficial use of the nursing process in addressing the needs of the client?

Provides a universally applicable framework for nursing activities

A nurse is providing care for clients in a long-term care facility. What should be the central focus of this care?

The client receiving the care

A community is defined as a social group that may or may not share common geographic boundaries yet interact because of

common interests

A community-based nurse acts as a case manager for a small town about 60 miles from a major healthcare center. What is the most important factor of community-based nursing for this nurse to be knowledgeable about?

community resources available to clients

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:

complete a postoperative assessment

Which assessment findings would support the nursing diagnosis of Impaired Skin Integrity? Select all that apply.

Unable to turn in bed without assistance uncontrolled diabetes unable to turn in bed without assistance

A novice nurse is sharing a newly published research article which outlines a different approach in preventing a wound infection after surgery with a colleague and states the nurse is going to try this new method. Which is the best response from the colleague?

Wait until the method is analyzed to ensure it will be appropriate for their clients.

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?

actual

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:`

actual or potential nursing diagnoses.

The nurse is explaining the expected developmental tasks of a typical family with adolescents. Which of the following would be incorrect for the nurse to include?

adjustment to retirement

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning

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?

discipline

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?

discovering a problem

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?

disturbed sleep pattern

Which is an important element of implementation?

documentation

Which is the priority question for the nurse to consider before implementing a new intervention?

does this treatment make sense for this client?

Which is a focus of medical research rather than nursing research?

drug metabolism

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?

dynamic

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?

evaluating

Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing?

evidence-based practice

When assessing a client's nonverbal communication, the nurse should assess which aspect as being the most expressive?

facial expressions

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?

repositioning the client

Which is an example of a nurse-initiated intervention?

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

A nurse is discussing cataract treatment with a client. Which statement by the nurse would be most therapeutic?

"Have you ever thought of laser surgery?"

A client was recently diagnosed with metastatic lung cancer. The nurse finds the client crying in the room. Which statement made by the nurse best demonstrates the use of empathy?

"I see you are upset. Would you like to talk?"

A nurse is asking a colleague about a situation. Which statement demonstrates assertive communication?

"I think there is a better way to handle this."

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

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

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?

"Is there another way to look at this situation?"

The client is talking to the nurse about recent health problems of immediate family members and the strain the client has been under trying to care for them. The client begins to cry. What response by the nurse demonstrates the most empathy?

"Just take your time. I am listening."

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?

0730: Client reports pain is a 7 on a scale of 0-10. Morphine sulfate 2 mg IV administered.

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?

Analyze the data and create an individualized nursing diagnosis.

A community health nurse has been visiting a diabetic client whose morning fasting glucose levels are constantly elevated. Upon further assessment, the nurse determines that the client's spouse does not understand how to prepare meals following the prescribed diabetic diet. Using Dorothea Orem's Self-Care Theory, how can the nurse help meet the needs of this client?

Arrange an evaluation appointment with a dietitian.

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality.

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill?

intellectual

Which statement best conveys the role of intuition in nurses' problem solving?

intuition can be a clinically useful adjunct to logical problem solving.

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

Which action exemplifies the purpose of evaluation in the nursing process?

Decide whether to continue, modify, or terminate client care.

Which are characteristics of critical thinking? Select all that apply.

It requires a conscious and deliberate effort. It requires a systematic and logical approach It involves judgments based on evidence.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame.

A registered nurse wishes to work as a nurse researcher. Which is true regarding nurse researchers?

They are responsible for the continued development and advancement of nursing.

The registered nurse (RN) working with a licensed practical nurse (LPN) understands which about LPNs?

They must take a licensure exam.

What is the purpose of the diagnosis phase of the nursing process?

To develop a prioritized list of client-centered problems

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?

assessment

A nurse takes the vital signs of a new hospital client admitted for severe abdominal pain. Which step of the nursing process is this nurse performing?

assessment

The Canadian Nurses Association (CNA) has published the standards of care for which the nurse is responsible. The Standards of Practice are:

assessment, diagnosis, outcome identification, planning, implementation, and evaluation.

The correct progression of steps of the nursing process is:

assessment, diagnosis, planning, implementation, and evaluation.

A nurse suspects that a client may have a hearing problem. The nurse should attempt to consult:

an audiologist

The nurse communicates with a newly admitted client. Which nonverbal behavior will the nurse note?

client's gestures

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process?

planning

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?

planning; implementing

Why are quality-assurance programs important in nursing?

They enable nursing to be accountable for the quality of care.

Which type of health problem requires both physician- and nurse-prescribed actions to address?

Collaborative health problem

What nursing activity forms the bridge between theory and practice?

Evidence-based research

How can the nurse obtain a more complete database for a newly admitted client?

comprehensive client assessment

A new graduate nurse asks a nurse manager working at the community health center, "I've heard people talk about community health nursing and community-based nursing. Is there a difference?" Which response by the nurse manager would be appropriate?

"Community health nursing involves care for entire populations whereas community-based nursing focuses on individuals and families in that population."

A nurse is planning education on self-administration of insulin to the client and the client's family members. The client asks the nurse why the family members are also included in the teaching. What should the nurse's response be?

"Family members are equally involved in planning and implementation of care."

A mother brings an infant into the clinic for a well-baby visit. The mother reports being concerned at discharge from the hospital after giving birth about being able to get the infant to latch on for breastfeeding. Now, however, the mother reports success with breastfeeding. and the nurse finds that the baby is gaining weight appropriately. Which is an appropriate evaluative statement for this client?

"8FEB2016. Goal met. Mother reports that breastfeeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight."

A mother is bringing an infant into the clinic for a well-baby checkup. The infant's weight gain is on target for age. A correctly written evaluative statement for this client is:

"8FEB2016. Goal met. The infant's weight gain is appropriate for age."

The nurse is collecting health data and avoids using closed-ended questions. Which are examples of closed-ended questions? Select all that apply.

"Are you ready to get out of bed?" "Do you smoke cigarettes?" "Is there any chance you might be pregnant?" "Does it hurt when I touch you here?"

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:

"We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time."

A client with a cardiac dysrhythmia was recently prescribed metoprolol and is at a follow-up appointment at the cardiologist's office. The client tells the nurse, "I feel depressed, tired, and I have no desire to exercise." To determine a cause-and-effect relationship, the nurse should ask:

"Were you tired and depressed before starting the new medication?"

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?

"client states, 'I don't see the point in trying anymore.'"

The nurse has entered the room of a newly admitted client who immediately reports feeling short of breath. After identifying this as the client's problem, the nurse uses the process of scientific problem solving. Place the steps in the order the nurse would follow.

1. collect assessment data 2. formulate a hypothesis 3. make a plan of action 4. perform hypothesis testing 5. evaluate

A nurse is providing care to an older adult client diagnosed with heart disease. The nurse uses the nursing process to provide individualized care using the actions listed below. Place the actions in the order that the nurse would most likely complete them using the nursing process.

1. obtain the client's vital signs 2. identifies risk for fluid volume excess 3. develops a realistic goal for monitoring fluid balance 4. prepares an individualized strategy for addressing risk 5. obtains the client's weight daily 6. determines that the client's fluid balance is stabilized

Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)?

A client report of shooting pain up the left leg

The nurse is evaluating client health. Which client should the nurse determine to be exhibiting the most signs of health?

A client with a leg amputation who performs activities of daily living with a prosthesis

What nursing care behavior by the nurse engenders a client to trust the nurse?

A nurse answers the client's questions about an upcoming test in a calm gentle voice while making eye contact with the client.

Which nurse would most likely be the best communicator?

A nurse who easily develops a rapport with clients

Which client requires priority intervention by a nurse providing care on a medical-surgical unit?

A postsurgical client who is feeling dizzy and has a heart rate of 45 beats/min

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

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

Which organization has established standards that help the nurse determine which clinical actions fall under the scope of nursing practice?

ANA (American Nurses Association)

A nurse is reading a research article from a nursing journal. The nurse is aware that the opening paragraph summarizing the article and the research findings is a good place to start. What part of the article is the nurse reading?

Abstract

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?

Add the nursing diagnosis: Risk for Self-Harm.

A nurse is caring for a client newly diagnosed with diabetes mellitus and developing a holistic plan of care. For this plan of care to be successful, it must what?

Address the disease but also incorporate the mind, body, and spirit

Which is the purpose of a focused assessment?

Adds depth to existing information

The nurse is caring for an underweight female 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?

Administer a high-calorie diet, excluding wheat, rye, and oats.

Which is an appropriately stated nursing intervention?

Ambulate 30 ft (9 m) twice a day with the assistance of a walker.

The first nursing journal owned, operated, and published by nurses was:

American Journal of Nursing

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action?

Ask the client to verbalize the medication regimen and diet modifications required.

A nurse is completing a health history on a client who has a hearing impairment. Which action should the nurse take first to enhance communication?

Assess how the client would like to communicate

The nurse delegates vital signs to be taken and recorded by the unlicensed assistive personnel (UAP). The UAP reports a blood pressure of 230/120 mm Hg on a client. Which is the nurse's priority action?

Assess the client and re-evaluate the vital signs.

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?

Assess the client's back visually.

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?

Assess the client's blood pressure to determine if the medication is indicated.

Put the phases of the nursing process in the correct order.

Assessment, diagnosis, planning, implementation, evaluation

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which nursing intervention best demonstrates caring in this situation?

Assisting the client to sit up in a chair

The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?

Auscultate the chest for breath sounds.

Which nursing action can be categorized as a surveillance or monitoring intervention?

Auscultating of bilateral lung sounds

A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response?

Be silent and allow the client to continue speaking when ready.

A nurse and an older adult client with chronic back pain are beginning to communicate. What activity should the nurse focus on at this point?

Being sensitive to the client's emotional barriers

Which is a psychomotor client goal?

By 18AUG2015, the client will demonstrate improved motion in the left arm.

Which statements are true about the implementation phase of the nursing process? Select all that apply.

Care provided during implementation should be documented in the client's chart. Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health.

A nurse is planning to pursue further education in the hopes of becoming an expert in geriatric nursing who carries out direct care. For which expanded career role is the nurse preparing?

Clinical nurse specialist

Which statement related to the evaluation of outcome attainment for a client is correct?

Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria.

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?

Consult with another nurse for that colleague's description of the assessment or observations.

Recording prioritized outcomes in the plan of care ensures which benefit?

Continuity of care can be provided to the client.

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Determine whether the prescribed treatment was effective.

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?

Developing accountability

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?

Developing the plan without client input

The nurse has developed a strong therapeutic relationship with an electrician who sustained severe burns while working on an industrial site. Which action by the nurse most directly addresses the client's self-actualization needs?

Discussing the client's strengths and dialoguing about body image

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?

Document this assessment based on the client's behaviors.

Which is the nurse's priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?

Does this task fall within the scope of a UAP?

Which action is a nursing intervention that facilitates lifespan care?

Educate family members about normal growth and development patterns.

Who is considered to be the first nursing theorist who conceptualized nursing in terms of manipulating the environment?

Florence Nightingale

Which is a characteristic of person-centered care?

It is a framework for providing care.

The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What should the nurse determine this phase will include? Select all that apply

Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client's record. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment

A client is distraught because a recent computed tomography (CT) scan shows that the client's colon cancer has metastasized to the lungs. Which nursing aim should the nurse prioritize in the immediate care of this client?

Facilitating coping

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which?

Finances of the client

On a particular 12-hour day shift, the nurse-client ratio on a busy floor is lower than usual because a member of the health care team called in sick for the day. Which example shows this nurse practicing with a good sense of legal competence in response to this challenge?

Following the chain of command, the nurse requests help completing the tasks essential to client care that day.

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?

Gastrointestinal upset from food poisoning

Which theory emphasizes the relationships between the whole and the parts, and describes how parts function and behave?

General systems theory

What type of nursing program would allow a student with a 4-year degree in psychology to enter and complete a baccalaureate degree in nursing, take the NCLEX examination, and transition into a Master of Science in nursing (MSN) program?

Graduate entry program

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client?

High Risk for Injury related to unsafe home environment

When developing nursing diagnoses, the nurse should focus on which area?

Human responses to actual or potential health problems

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?

Impaired Physical Mobility related to pain

A nurse manager is teaching staff how to use a new piece of hospital equipment. Which educational setting would be most appropriate for this process?

In-service education

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?

Ineffective Health Maintenance related to client's denial of illness

Which provides the best framework for prioritizing client problems?

Maslow's hierarchy of needs

A nurse is caring for a 78-year-old client who has been hospitalized following a stroke. Which nursing action has the highest priority for this client?

Measuring the client's intake and output during recovery

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?

Modify the plan of care and interventions to meet the client's needs.

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA-International (NANDA-I)

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?

Notify the physician for additional orders.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

Which statements are true about informatics in nursing practice? Select all that apply.

Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. Utilization of information services helps to support decision making.

What is the best explanation for the way evidence-based practice (EBP) has changed the way nursing care is delivered?

Nursing care now uses EBP as a means of ensuring quality care.

What might a nurse need to do to ensure the continuation of his or her nursing license?

Obtain continuing education credits.

Due to the rising cost of health care services, many procedures and treatments are being delivered in what type of setting?

Outpatient facilities

A nurse is developing a foreground question for nursing research using the PICO model. Which component would be represented by the statement, "a 45-year-old male with coronary heart disease and atrial fibrillation"?

P

A client whose care plan includes a nursing diagnosis of "Risk for Infection related to a disruption of skin integrity secondary to abdominal surgery" is displaying redness, edema, and warmth at the surgical site. What would be the nurse's most appropriate revision of the care plan?

PC: Infection related to disrupted skin integrity secondary to abdominal surgery

Which is the most appropriate example of the assessment phase of the nursing process?

Palpating a mass in the right lower quadrant of the abdomen

A nurse identifies an area where client care has been compromised. What steps should the nurse take to improve performance? Select all that apply.

Plan a strategy using indicators. assess the change discover a problem implement a change

A group of nurses is planning to investigate the effectiveness of turning immobilized stroke clients more frequently in order to prevent skin breakdown. The team has begun by formulating a PICO question. Which element will the "O" in the team's PICO question refer to?

Preventing skin breakdown

Which nursing actions reflect the implementing step of the nursing process? Select all that apply.

Providing health education to reduce health risks Referring the client to community resources, when necessary Using evidence-based interventions individualized for the client

Which is the best example of person-centered care provided by a registered nurse?

Reassuring a client who is anxious about a procedure

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?

Recheck the temperature, paying close attention to technique.

In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged?

Reevaluating experience in light of ideas

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?

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.

What should the nurse do prior to performing an initial assessment on a newly admitted client?

Review the records available on the client.

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?

Risk for Community Contamination related to possible environmental pollution

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

Which are characteristics of one who has developed critical thinking skills?

Self-aware, honest, persistent, and authentic

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?

Tell the UAP that the RN will assist the UAP with the client's ambulation.

The nurse is caring for a mother and newborn baby couplet. The mother has a nursing diagnosis of insufficient breast milk but wants to continue to breast feed. The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the baby is gaining weight. What is the most appropriate action by the nurse at this time?

Terminate the plan of care because evaluation reveals that the outcome has been met.

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?

The amount and type of drainage suctioned from the nares, and the client's response

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?

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

Which outcome should the nurse recognize as being the most appropriate for a client with a nursing diagnosis of risk for infection?

The client has a normal temperature and no signs or symptoms of infection.

A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem?

The client is able to explain when and why the client needs to check the blood glucose level.

Which are cognitive client outcomes? Select all that apply.

The client lists the side effects of digoxin. The client describes how to perform progressive muscle relaxation. The client identifies signs and symptoms of hypoglycemia.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply.

The client verbalizes understanding of the instructions. The client is able to answer the nurse's questions. The client discusses the specifics of what was taught during the session.

Which outcome for a client with a new colostomy is written correctly?

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

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?

The client will maintain a pulse oximeter reading of greater than 94% (0.94 L).

Which factor is most likely to contribute to the nurse making a diagnostic error?

The client withholds information during the client assessment.

Which is the primary reason for a nurse collecting data continuously on a client?

The client's health status can change quickly.

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.

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

The home health nurse is making an initial assessment visit to a family that consists of two parents and twin 3-year-old boys. During the interview, the nurse is most concerned if the client makes which statement?

The father states, "I don't discuss money matters with my wife because I don't want her to worry."

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

The client is able to explain when and why the client needs to check the blood glucose level.

The nurse and client measure achievement of planned outcomes of care.

Which of the following best summarizes the evaluation step of the nursing process?

The nurse and client measure achievement of planned outcomes of care.

Which is the best example of a client-centered approach to care?

The nurse asks the client about health goals.

Which nursing action reflects evaluation?

The nurse assesses the client's response to pain medication.

A nurse working on a busy acute care unit is planning care for a group of clients. Which nursing action best exemplifies the primary focus of the nurse's role?

The nurse comforts a client who received bad results from a diagnostic test.

Which characteristic is the most important indicator of high-quality nursing practice?

The nurse considers the individual needs of clients.

The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up?

The nurse encourages the client to participate in all treatment decisions as the center of the health care team.

A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse?

The nurse evaluates the client's goal/outcome achievement.

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training?

The nurse introduces oneself to the client by pointing to the nurse's name badge.

A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply.

The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete.

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?

The nurse should determine the reason for the client's refusal.

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?

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:

a cognitive outcome

A nurse is preparing to conduct a research study and uses the PICO format to develop the foreground question which is: "In adults, does reducing salt intake, compared to no change in salt intake, lower blood pressure?" The nurse identifies the "P" as:

adults

A nurse must possess several characteristics to be successful in this profession. Secondary to critical thinking skills, which is of great value?

advocating for the client at all times

A home health nurse is visiting a family after the recent death of their matriarch. The nurse observes that the family is dressed in black, all of the mirrors are covered, and that the immediate family is sitting on square wooden boxes instead of chairs. The nurse asks what is happening, and is told, "We are Jewish, and the family is 'Sitting Shiva'." This family is fulfilling which family function?

affective and coping functions

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?

another registered nurse with critical care certification

A nurse is considering relocating to another state to practice nursing. Which is the most appropriate action by the nurse to ensure ability to practice in the new state?

applying for a reciprocal license in the new state

The nurse is caring for a client with a new diagnosis of cancer, and allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing?

art of nursing

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?

as soon as possible

The nurse is delegating tasks to the unlicensed assistive personnel (UAP) prior to beginning the shift on the acute care unit. Which task would be appropriate to delegate to the UAP?

assisting an older adult client with using the bedside commode

Which are characteristics of a critical thinker? Select all that apply.

being open to all points of view resisting easy answers to client problems thinking outside the box

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

bowel incontinence

A nurse develops the following foreground question using the PICOT format in preparation for a research study: "In overweight clients, how do chromium supplements compared to no supplements help with weight loss?" Which part of the question reflects the intervention?

chromium supplements

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?

clarity

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

client is normotensive

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented?

clinical reasoning

"The client will verbalize appropriate cast care on discharge" represents which type of outcome?

cognitive

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:

complete an exam of all body systems.

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:

completely unmet

When the nurse researcher informs the participant that the participant's identity will not be linked with the information that is collected, the researcher is ensuring the participant's:

confidentiality

Which example of client care is not the responsibility of the nurse?

confirming a medical diagnosis

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:

create an exercise plan that is realistic and valued.

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

descriptors

The nurse analyzes client data to identify client strengths and health problems that independent nursing interventions can prevent or resolve. Which step of the nursing process is the nurse performing?

diagnosing

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?

diagnosis

Which step of the nursing process involves reporting or analysis of data to identify and define health problems?

diagnosis

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?

educational

A nurse is preparing to provide discharge instructions to a postpartum client regarding infant care. Before beginning the education session, the nurse should:

eliminate as many distractions as possible

A family has lost a member who was treated for leukemia at a nursing unit. The nurse provides emotional support to the family and counsels them to cope with their loss. Which quality should the nurse use in this situation?

empathy

The nurse works as a client advocate for an older adult client admitted with hyponatremia. Which action can the nurse take to help the client advocate for oneself?

encourage the client to ask questions

A nurse is performing a sterile dressing change on a client's abdominal incision. While establishing the sterile field, the nurse drops the forceps on the floor. The nurse is unable to continue with the dressing change because there are no extra supplies in the room, and no one is present to bring new forceps. The nurse failed to organize:

equipment and personnel

A nurse who works in a pediatric practice assesses the developmental level of children of various ages to determine their psychosocial development. These assessments are based on the work of:

erikson

A nursing theorist examines a hospital environment by studying each ward and how it works individually, and then relates this information to the hospital as a whole working entity. This is an example of the use of which theory?

general systems theory

One of the primary reasons for conducting nursing research is to:

generate knowledge to guide practice

A nurse who is preparing to administer an injection to the client states, "This injection will not be painful." The nurse has used which communication technique?

giving false reassurance

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?

hierarchy of human needs

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

identifies factors causing undesirable response and preventing desired change.

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.

impaired mobility, ineffective coping, imbalanced nutrition

Which are stressors that affect the health of the family?

inadequate childcare services

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?

intuitive

A nurse is providing care to a 3-year-old child admitted with a diagnosis of infectious diarrhea. The nurse needs to insert an intravenous catheter in order to administer prescribed intravenous fluids. In an attempt to foster communication, the nurse should:

involve the child's stuffed animal in the educational session.

Which are examples of objective data? Select all that apply.

laboratory test results breath sounds on auscultation a client's temperature

A modern approach to the development of clinical decisions and clinical judgments is the use of human client simulators in simulation laboratories on campus. Human client simulators are best described as:

life-sized mannequins with a sophisticated computer interface.

The student nurse is combing through various medical websites searching for information to answer a research question for a class assignment. Which note(s) would indicate the nurse is referencing a reputable website? Select all that apply.

list of references, site reviewed last year, author's email address

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

objective

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?

ongoing

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?

outcome

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?

outcome

A nurse is engaged in the assessment phase of the nursing process. When completing the physical exam, which techniques would the nurse likely use? Select all that apply.

palpating, inspecting, auscultating, percussion

During the nurse's admission interview the client says, "I don't get too much rest because I am in nursing school and work full time to support myself and my kids." The nurse classifies this statement as an issue at which level of Maslow's basic needs?

physiologic

The nurse is conducting a home assessment and suggests that the client's family remove scatter rugs from the home and increase the lighting. Which basic human need is being addressed by the nurse's suggestions?

safety and security

A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea?

sit with client and ask about their feelings

Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family?

socialization

"The levels of performance accepted by and expected of nursing staff or other health team members" defines:

standards

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?

standarized

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:

structure

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

subjective

The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as

supervisory

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?

supportive

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?

surveillance

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?

surveillance

A nurse is attempting to calm an infant in the nursery. The nurse responds to the highest developed sense by:

swaddling the child and gently stroking its head.

A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because the nurse has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should:

tell oneself to "remain calm" and remember that the nurse was trained to perform this skill.

A dialysis nurse is educating a client on caring for the dialysis access that was inserted into the client's right arm. The nurse assesses the client's fears and concerns related to dialysis, the dialysis access, and care of the access. This information is taught over several sessions during the course of the client's hospitalization. Which phase of the working relationship is best described in this scenario?

the working phase

One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated?

throughout the client's hospital admission

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?

time-lapsed assessment

The nurse is caring for a client after a stroke rendered the client's right side weaker than the left. The nurse coordinates the plan of care with the physical therapist. The nurse's interventions reflect which one of nursing's four broad goals?

to restore health

A nurse working in a long-established hospital learned a specific approach to administering intravenous injections from the previous generation of nurses at the hospital. This is an example of which type of knowledge?

traditional knowledge

Evidence-based care emphasizes decision making based on the best available evidence and:

use of outcome studies to guide decisions

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:

uses critical thinking to direct care for the individual client.

Although all of the following are nursing responsibilities, which one would be expected of a nurse with a baccalaureate degree?

using research findings to improve practice

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent?

verb (action)

The nurse is providing education to a client who sometimes has difficulty remembering information. Which form of communication will be most helpful for this client?

written communication