NURS 101 final nursing process PREPU & powerpoint info

Which source of information helps a nurse formulate nursing diagnoses for a specific client? a. Admission criteria b. Research articles c. Essential assessment data d. Outcome criteria

c. Essential assessment data

what are the two time based types of outcomes for planning?

short-term long-term

what are the three parts of nursing diagnostic statements?

state the problem state the etiology (related to) state the defining characteristics that give evidence (as evidenced by)

how to assess

gather data about the Pt validate data analyze, cluster, group data document findings

the basics of evaluation

identify expected outcome collect data to determine if the outcome is met interpret and summarize findings document your judgement terminate, continue, or modify plan

direct intervention

is done directly for Pt

planning outcomes are SMART

Specific Measurable Attainable Realistic Time-bound

A 17-year-old high school senior calls the clinic because she thinks she might have gonorrhea. She wants to be seen but wants assurances that no one will know. Which is the most appropriate response by the nurse? a. "We can see you without your parents' consent but have to report any positive results to the public health department." b. "We can treat you without your parents' consent, but they have the right to review your medical record." c. "We can see you and will not share your results with anyone." d. "Because you are underage, we will need your parent's consent to treat you."

a. "We can see you without your parents' consent but have to report any positive results to the public health department.

A nurse is caring for a client who speaks only French. The client's granddaughter is bilingual and assists with translating, but the nurse needs to provide the client with discharge instructions. Which of the following would be the best option for the nurse and the client? a. Ask the manager to find an interpreter who is able to provide the discharge instructions. b. Document on the medical record that discharge instruction was not provided due to a language barrier. c. Provide written instructions in English, and ask the granddaughter to translate them at home. d. Provide the information to the granddaughter, and have her do the translation in the nurse's presence.

a. Ask the manager to find an interpreter who is able to provide the discharge instructions.

Which of the following involves charting information about the client and client care in chronological order? a. Narrative charting. b. PIE charting. c. Focus charting. d. SOAP charting.

a. Narrative charting.

A client is transferred from the coronary care unit to the step-down unit. Which information should be included in the transfer report? Select all that apply. a. The client has a "do not resuscitate" prescription. b. The client uses the bedpan. c. The client has been in normal sinus rhythm for 6 hours. d. The client needs oxygen at 2 L/minute. e. The client has four grandchildren.

a. The client has a "do not resuscitate" prescription. b. The client uses the bedpan. c. The client has been in normal sinus rhythm for 6 hours. d. The client needs oxygen at 2 L/minute.

A 22-year-old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7, and he demonstrates evidence of decorticate posturing. Which action is appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring? a. The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent. b. The nurse will obtain a signed consent from the client's fiancée because he is of legal age and they are engaged to be married. c. Two nurses will receive a verbal consent by telephone from the client's next of kin before inserting the catheter. d. The health care provider (HCP) will get a consultation from another health care provider and proceed with placement of the ICP catheter until the family arrives to sign the consent.

a. The health care provider will document the emergency nature of the client's condition and that an ICP catheter for monitoring was placed without consent.

What is the nurse expected to do when filing a report about an incident of finding an elderly client with mild dementia on the floor? a. The nurse must file an incident or adverse event report. b. The nurse must chart about the incident and communicate in a report about the event. c. The nurse is aware that adverse reports are not confidential material, so only documentation in the chart should be completed. d. The nurse must communicate the event to the charge nurse, who will document the fall in an adverse reporting system.

a. The nurse must file an incident or adverse event report.

An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client? a. Use a nightlight in the bathroom. b. Keep all four side rails up at all times. c. Place the client in a room with a camera monitor. d. Keep all the lights on in the room at all times.

a. Use a nightlight in the bathroom

Which approach is the best way for the nurse to begin the preoperative interview? a. Walk in the client's room, sit down, maintain eye contact, and make an introduction. b. Walk in the client's room, and ask the client's name. c. Walk in the client's room and ask, "Are you Mrs. Smith?" d. Walk in the client's room, sit down, and take the client's blood pressure.

a. Walk in the client's room, sit down, maintain eye contact, and make an introduction.

The nurse on the postpartum unit is caring for four couplets. There will be a new admission in 30 minutes. The new client is a G4 P4, Spanish-speaking only client with an infant who is in the special care nursery (SCN) for respiratory distress. The nurse should place the new client in a room with which client? a. a G4 P4 who is 2 days postpartum with infant, Spanish speaking only b. a G1 P1 who is a non-English speaking client with infant in SCN for fetal distress c. a G6 P6 who gave birth 4 hours ago by C/S for fetal distress, infant at bedside d. a G1 P1 who is 1 day postpartum with an infant in the SCN

a. a G4 P4 who is 2 days postpartum with infant, Spanish speaking only

A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today, but had to cancel the appointment when the child became ill. The nurse should: a. arrange for the pump to be refilled in the hospital. b. instruct caregivers to call for a refill when the low-volume alarm sounds. c. reschedule the pump refill for the day of discharge. d. explain that the medication should be discontinued during illness.

a. arrange for the pump to be refilled in the hospital.

When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply. a. that the client understood the information b. that there was adequate disclosure of information c. that there was voluntary consent on the client's part d. that the client's relative, spouse or legal guardian was present e. that the client has full awareness of the potential complications

a. that the client understood the information b. that there was adequate disclosure of information c. that there was voluntary consent on the client's part e. that the client has full awareness of the potential complications

The nurse manager is developing a "read-back" procedure to reduce medication administration errors. Which are purposes of the "read-back" requirement? Select all that apply. a. to make sure that prescriptions and test results that are communicated verbally or by telephone are confirmed by the individual giving the information b. to encourage the use of electronic medical records c. to make sure that prescriptions and test results that are communicated verbally or by telephone are clear to the receiver of the information d. to minimize the risk of nonauthorized personnel from giving prescriptions which are communicated verbally or by telephone e. to prohibit prescriptions and test results from being communicated verbally or by telephone

a. to make sure that prescriptions and test results that are communicated verbally or by telephone are confirmed by the individual giving the information c. to make sure that prescriptions and test results that are communicated verbally or by telephone are clear to the receiver

independent intervention

are the autonomous actions of the nurse, and based on the nursing diagnoses and client-centered goals

Nursing process (ADPIE)

assessment: gather data nursing diagnosis: analyzing the problem to formulate diagnosis planning: write care plan to meet goals implementation: carry our plan evaluation: collect objective date to determine the extent to which goals were achieved. revise plan as needed

A client in a long-term care facility signed a form requesting not to be resuscitated. The client develops pneumonia, and the client's health rapidly deteriorates. The client is no longer competent, but the family wants everything possible done for the client. When the family asks the nurse what will be done, what is the best response by the nurse? a. "We will resuscitate the client only if there is a respiratory arrest." b. "We will continue to use antibiotics to treat the pneumonia." c. "We will not provide any pharmacologic intervention at this time." d. "We will honor the family's wishes because the client cannot make decisions."

b. "We will continue to use antibiotics to treat the pneumonia."

A nurse overhears another nurse say to a client, "If you do not stop spitting, I'm going to leave you outside in your wheelchair so that you miss your dinner." What is the most appropriate response by the nurse who overhears this conversation? a. "I think you need to review therapeutic communication techniques." b. "Your verbal threats to the client are legally considered assault." c. "I will have to report you for unprofessional behavior toward a client." d. "Could you clarify for me whether you were joking with the client?"

b. "Your verbal threats to the client are legally considered assault."

Which of the following clients is the most appropriate candidate for outpatient care? a. A man who is receiving treatment for sepsis after his blood culture came back positive. b. A client whose reports of irregular bowel movements have necessitated a colonoscopy. c. A client with a history of depression who is currently expressing suicidal ideation. d. A woman who has previously borne two children and is entering the second stage of labor.

b. A client whose reports of irregular bowel movements have necessitated a colonoscopy.

A nurse has completed 4 hours of his 8-hour shift on a medical-surgical unit when he receives a phone call from the nursing supervisor. The nursing supervisor informs the nurse that he needs to give report to the other two nurses on the medical-surgical unit and immediately report to the telemetry unit to assist with staff needs on that unit. The nurse informs the supervisor that he has been busy with his client assignment and feels this will overwhelm the nurses on the medical-surgical unit. The supervisor informs the nurse that the need is greater on the telemetry unit. This is an example of which type of ethical problem? a. Deception. b. Allocation of scarce nursing resources. c. Conflicts concerning new technology. d. Advocacy in a market-driven economy.

b. Allocation of scarce nursing resources.

Which strategy is the most effective for a nurse to use to reduce the number of children involved in automobile accidents who were not wearing seat belts? a. Call the town mayor's office with this information so that the mayor can discuss it with the media. b. Attend a school board meeting to advocate for classes teaching children seat belt safety. c. Contact the local government representative to discuss new legislation about child seat belts. d. Start a letter-writing campaign to the school superintendent about seat belt importance.

b. Attend a school board meeting to advocate for classes teaching children seat belt safety.

A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports? a. Wait for the physicians to arrive before exchanging notes. b. Come prepared with the material required to take notes. c. Avoid asking questions related to the medical record. d. Speak individually to each staff member before attending the meeting.

b. Come prepared with the material required to take notes.

Which activities should the nurse encourage the unlicensed assistive personnel (UAP) to assist with in the care of postoperative clients? Select all that apply. a. Teach clients the proper use of the incentive spirometer. b. Empty and measure indwelling urinary catheter collection bags. c. Reposition clients for pain relief. d. Tell the nurse if clients report they are having pain. e. Assess IV insertion site for redness.

b. Empty and measure indwelling urinary catheter collection bags. c. Reposition clients for pain relief. d. Tell the nurse if clients report they are having pain

Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation? a. Minimal serous wound drainage b. Temperature of 102° F (38.9°C) c. Staples intact to incision d. Skin intact over bony prominences

b. Temperature of 102° F (38.9°C)

A nurse notes that a client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client? a.The client will enjoy visits from other clients admitted to the same unit. b. The client will permit the nurse to speak with him for a 5-minute period by day 2 of hospitalization. c. The client will approach the nurse to ask for a magazine. d. The client will visit the window outside of the newborn nursery to see the new babies.

b. The client will permit the nurse to speak with him for a 5-minute period by day 2 of hospitalization.

Which of the following is a cultural norm of the healthcare system? a. The omnipotence of technology is yet to be recognized. b. There is the use of a systematic approach and problem-solving methodology. c. There is a tolerance of tardiness, disorderliness, and disorganization. d. There is high flexibility in certain procedures attending birth and death.

b. There is the use of a systematic approach and problem-solving methodology.

When obtaining a client's history, the nurse should: a. palpate the client's abdomen. b. ask questions about the client's reason for seeking care. c. document medication administered. d. auscultate for the client's breath sounds.

b. ask questions about the client's reason for seeking care.

The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The nurse has a religious objection and wishes to refuse to participate in an abortion. The nurse manager of the operating room should: a. change the assignment and record the behavior on the nurse's evaluation. b. change the assignment without comment. c. require the nurse to do this assignment. d. change the assignment to circulate but have the nurse prepare the equipment.

b. change the assignment without comment.

The hospital is responding to a mass casualty disaster with adult and pediatric victims. After reallocating staff, the charge nurse on the pediatric floor should: a. change taking all vital signs to every 8 hours. b. review the census for clients that are candidates for early discharge. c. initiate paper charting backup. d. ask parents to leave to free up the parent sleep areas for incoming victims.

b. review the census for clients that are candidates for early discharge.

When creating a program to decrease the primary cause of disability and death in children, the nurse should: a. encourage legislators to draft legislation to promote prenatal care. b. teach health and safety practices to children and their parents. c. require all children to be immunized. d. hire a nurse practitioner for each of the schools in the community.

b. teach health and safety practices to children and their parents.

During the preoperative interview, the nurse obtains information about the client's medication history. Which information is not necessary to record about the client? a. over-the-counter medication use in the last 6 weeks b. use of all drugs taken in the last 18 months c. steroid use in the last year d. current use of medications, herbs, and vitamins

b. use of all drugs taken in the last 18 months

Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next? a. Send the nurse's assistant to the x-ray department to bring the client back to his room. b. Bring a small glass of juice, and locate the client. c. Check the computerized care plan to determine what test was scheduled. d. Call the client's health care provider (HCP).

c. Check the computerized care plan to determine what test was scheduled.

A hospital uses the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? a. "Client has a history of recent abdominal pain." b. "2 mg hydromorphone PO administered with good effect." c. "Client reporting abdominal pain rated at 8/10." d. "Client is guarding her abdomen and occasionally moaning."

c. "Client reporting abdominal pain rated at 8/10."

Which statement reflects appropriate documentation in the medical record of a hospitalized client? a. "Client seems to be mad at the physician." b. "Small pressure ulcer noted on left leg." c. "Client's skin is moist and cool." d. "Client had a good day."

c. "Client's skin is moist and cool."

A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client? a. "Monitor fluid intake and output every 4 hours." b. "There is a risk for infection related to I.V. insertion." c. "The client remains free of signs and symptoms of phlebitis." d. "Edema and warmth are noted at I.V. insertion site."

c. "The client remains free of signs and symptoms of phlebitis."

A nurse is admitting a client to the palliative unit and discussing advanced directives. Which of the following statements made by the client leads the nurse to believe the client requires clarification around advanced directives? a. "I can let my family know what treatment I want in the future." b. "It is good to do this now before I am unable to make the decisions." c. "This will stop my daughter-in-law from putting me in a home." d. "This will allow me to identify who my power of attorney will be."

c. "This will stop my daughter-in-law from putting me in a home."

A community nurse arrives at the home of a client. The client is in soiled clothes due to the inability to make it to the bathroom in time. The nurse overhears the unregulated care provider (UCP) scolding the client for the soiled clothes. What is the most appropriate response by the nurse to the UCP? a. "You need to have more training in therapeutic communication." b. "Why weren't you there to help the client get to the bathroom?" c. "Your behavior in this situation is considered verbal abuse." d. "I'm sure you didn't mean to hurt the client's feelings, but you did."

c. "Your behavior in this situation is considered verbal abuse."

When coaching a client to improve their health, which strategy is the most effective for the nurse to use to help clients take an active role in their health care? a. Provide clients with written instructions. b. Ask clients if they have any questions about their health. c. Ask clients for their views of their health and health care. d. Ask clients to complete a questionnaire.

c. Ask clients for their views of their health and health care.

Each morning, a nurse-manager assigns clients and additional tasks for the staff nurses to complete that day. During the shift, a crisis develops and one staff nurse doesn't complete the additional tasks. The next day, the nurse-manager reprimands this nurse. When the nurse tries to explain, the nurse-manager interrupts, saying that the nurse should have completed the tasks no matter what happened. Which leadership style is the nurse-manager exhibiting? a. Laissez-faire b. Democratic c. Autocratic d. Permissive

c. Autocratic

A client has experienced a postpartum hemorrhage. The health care provider (HCP) verbally prescribed carboprost tromethamine 0.25 mg IM stat at the time of the hemorrhage, and this was given by the nurse. The HCP put an order into the medical record for 0.25 mg carboprost tromethamine IV stat. When seeing the order, how should the nurse administering the carboprost tromethamine respond? a. Wait until the HCP returns to the unit and discuss the situation in person. b. Initiate an incident report. c. Call the HCP, discuss the prescription, and request revision if heard correctly. d. Ask the charge nurse to have a discussion with the HCP about the order.

c. Call the HCP, discuss the prescription, and request revision if heard correctly.

A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside her bed after falling when trying to ambulate to the washroom. After assessing and assisting the client back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? a. Gauging the nurse's professional performance over time. b. Protecting the nurse and the hospital from litigation. c. Identifying risks and ensuring future safety for clients. d. Following up the incident with other members of the care team.

c. Identifying risks and ensuring future safety for clients.

A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? a. Impaired physical mobility related to surgery b. Deficient fluid volume related to blood and fluid loss from surgery c. Ineffective airway clearance related to anaesthesia d. Acute pain related to surgery

c. Ineffective airway clearance related to anaesthesia

To which unlicensed assistive personnel (UAP) should the nurse assign a male orthodox Muslim client who needs complete morning care? a. Jim, who has five clients requiring partial morning care b. Jill, who has four clients requiring partial morning care c. Joe, who has one client requiring complete morning care d. Mary, who has two other clients requiring complete morning care

c. Joe, who has one client requiring complete morning care

A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, he has seen significant improvements in both his medical status and activities of daily living (ADLs). This morning, however, his nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which of the following practitioners should the nurse liaise with to obtain a swallowing assessment? a. Physician. b. Physical therapist. c. Speech therapist. d. Respiratory therapist.

c. Speech therapist.

A nurse asks a client to sign the consent for surgery. Which of the following is an appropriate situation for giving valid consent? a. The client tells the nurse that the physician is capable and signs without reading the information on the consent. b. The client has his/her spouse sign because the client is in too much pain from the condition. c. The client has cognitive capacity to make decisions. d. The client still has further questions about the surgery, but the nurse encourages the consent to be signed and will attach a note to the chart for the physician.

c. The client has cognitive capacity to make decisions.

The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan? a. Hepatitis B is relatively uncommon among college students. b. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B. c. The use of a condom is advised for sexual intercourse. d. Good personal hygiene habits are most effective at preventing the spread of hepatitis B.

c. The use of a condom is advised for sexual intercourse.

After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first? a. a client with pancreatitis whose family requests to speak with the HCP regarding the treatment plan b. a client with stable vital signs that has been receiving IV cipro following a cholecystectomy for 1 day and has developed a rash on the chest and arms c. a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular d. a client with cirrhosis who is depressed and has refused to eat for the past 2 days

c. a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular

A client is to have a below-the-knee amputation. Prior to surgery, the circulating nurse in the operating room should: a. start an intravenous infusion. b. verify that the surgeon possesses the degree of expertise needed. c. initiate a time-out. d. insert a Foley catheter.

c. initiate a time-out.

A postmenopausal client is scheduled for a bone-density scan. The nurse should instruct the client to: a. report any significant pain to the health care provider (HCP) at least 2 days before the test. b. consume foods and beverages with a high content of calcium for 2 days before the test. c. remove all metal objects on the day of the scan. d. ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test.

c. remove all metal objects on the day of the scan.

what some evaluation statements?

outcome met outcome partially met outcome not met data that supports conclusion

what types of nursing diagnosis are there?

potential complications collaborative problems actual/ risk nursing diagnoses wellness diagnoses

dependent intervention

require the order of a physician

A client is placed on a low-sodium (1500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective? a. "I will have bacon and eggs for breakfast every day." b. "I can still eat a ham and cheese sandwich with pickles for lunch." c. "I chose a tossed salad with olives and oil and vinegar dressing for lunch." d. "I chose broiled chicken with a baked potato for dinner."

d. "I chose broiled chicken with a baked potato for dinner."

When developing a care plan for an older adult, a nurse should consider which challenges that clients in this age-group face? a. Developing leisure activities, preparing for retirement, and resolving empty-nest crises b. Selecting vocation, becoming financially independent, and managing a home c. Managing a home, developing leisure activities, and preparing for retirement d. Adjusting to retirement, deaths of family members, and decreased physical strength

d. Adjusting to retirement, deaths of family members, and decreased physical strength

A nurse has completed 4 hours of his 8-hour shift on a medical-surgical unit when he receives a phone call from the nursing supervisor. The nursing supervisor informs the nurse that he needs to give report to the other two nurses on the medical-surgical unit and immediately report to the telemetry unit to assist with staff needs on that unit. The nurse informs the supervisor that he has been busy with his client assignment and feels this will overwhelm the nurses on the medical-surgical unit. The supervisor informs the nurse that the need is greater on the telemetry unit. This is an example of which type of ethical problem? a. Deception. b. Advocacy in a market-driven economy. c. Conflicts concerning new technology. d. Allocation of scarce nursing resources.

d. Allocation of scarce nursing resources.

A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, what would be the most appropriate outcome for the couple to accomplish by the end of this visit? a. Choose an appropriate infertility treatment method. b. Discuss alternative methods of having a family, such as adoption. c. Acknowledge that only 50% of infertile couples achieve a pregnancy. d. Describe each of the potential causes and possible treatment modalities.

d. Describe each of the potential causes and possible treatment modalities.

A health care agency is applying for accreditation, and the accrediting agency is conducting audits of randomly selected medical records. To support the agency's accreditation, these medical records should include: a. Evidence that nurses have set goals for improving future practice. b. Evidence of home care and nursing follow-up for 6 weeks following discharge. c. Self-reflection from nursing and other care providers about he quality of their care. d. Evidence that nursing interventions have been evaluated in terms of the client's response.

d. Evidence that nursing interventions have been evaluated in terms of the client's response.

A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment? a. Notify the supervisor that this is a relative but the relationship will not be a conflict. b. Ask the aunt if she would like the nurse to take care of her while in the hospital. c. Accept the assignment and not disclose the relationship with the client. d. Notify the supervisor and provide care until another nurse can be assigned to the client.

d. Notify the supervisor and provide care until another nurse can be assigned to the client.

The nurse is assessing a 16-year-old nulligravida, who asks for information on natural family planning methods of contraception and reports that her menstrual cycle occurs every 28 days. Which information would be important to include in the teaching plan for this client? a. The ovum survives for 96 hours after ovulation, making conception possible during this time. b. The basal body temperature falls at least 0.2°F (0.1°C) after ovulation has occurred. c. Most women can tell they have ovulated because of severe pain and thick, scant cervical mucus. d. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle.

d. Ovulation usually occurs on day 14, plus or minus 2 days, before the onset of the next menstrual cycle.

The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? a. The outer inch of the sterile towel hangs over the side of the table. b. Sterile packages are opened with the first edge away from the technician. c. Sterile objects are held above the waist of the technician. d. Wetness in the sterile cloth on top of the nonsterile table has been noted.

d. Wetness in the sterile cloth on top of the nonsterile table has been noted.

The labor and birth nurse is assigned to triage for the day. There are four clients already in rooms, and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first? a. a primipara in active labor at 5 cm asking to be admitted and wanting an epidural b. a primipara who is 100% effaced, 8 cm dilated, + 2 station with nausea c. a client with no prenatal care, occasional contractions, BP 148/90 mm Hg, and swollen feet d. a client who is at 42 weeks' gestation with bloody show, no contractions, rupture of membranes 1 hour ago leaking green fluid

d. a client who is at 42 weeks' gestation with bloody show, no contractions, rupture of membranes 1 hour ago leaking green fluid

The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect: a. increased forced expiratory volume. b. morning headaches. c. normal breath sounds. d. inspiratory and expiratory wheezing.

d. inspiratory and expiratory wheezing.

Which information is appropriate to include in an incident report? a. an interpretation of the likely cause of the incident b. the extenuating circumstances involved in the situation c. the client's statement about the incident that occurred d. what the nurse saw and did

d. what the nurse saw and did

what are the purposes of planning?

establish priorities identify expected outcomes set goals select evidence-based interventions communicate the plan of care

indirect intervention

is done on behave for the Pt

basics of implementing

means of implementation: psychomotor skills, education, counseling, advocating resources for implementation: equipment, environment, personnel, patient/ family/ visitors delegate when permissible remember documentation **remember your skill level, education & legal limits**

when planning outcomes must be __________.

measurable **Pt will... define, demonstrate, list, choose, explain, verbalize

what are factors that guide planning?

the Pt interests and preferences are central in planning research must support your plan

how to establish a nursing diagnosis

the problem(s) and clarify what is causing it/them reasoning **not assumptions** terms and defining features are approved by NANDA unique focus- identifies the human response and the need for nursing