Nursing Process

You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?

A rapid, bounding pulse

The nurse is performing a neurologic assessment on a client diagnosed with a stroke and cannot elicit a gag reflex. This deficit is related to which of the following cranial nerves?

X

While completing an abdominal assessment, the nurse will use which landmark as the upper boundary for auscultating bowel sounds?

Xiphoid process

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?

a feeling of swelling at the back of the throat

To calculate the ideal body weight for a woman, the nurse allows for which of the following?

100 lb for 5 ft of height

A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse?

"Describe the pain and rate it on the pain scale."

A client has been placed on a ventilator, and the spouse begins to cry during the initial visit. What is the best therapeutic statement for the nurse to communicate?

"Tell me what you are feeling."

A patient's serum sodium concentration is within the normal range. What should the nurse estimate the serum osmolality to be?

275-300 mOsm/kg

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome?

3 hours

A nurse is preparing a plan of care for a client with otitis externa. Based on the typical assessment findings, which of the following would the nurse most likely identify as the priority nursing diagnosis?

Acute pain related to inflammation

Which is one of the most common causes of death in clients diagnosed with fat emboli syndrome?

Acute respiratory distress syndrome

The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care?

Advice for the family to have fruit juices readily available at the client's bedside.

A client arrives at the orthopedic physician's office stating knee pain sustained while playing soccer. A history and physical assessment is completed. The knee appears reddened with edema. Which other diagnostic testing would the nurse anticipate?

An arthroscopy

A nurse is receiving a client to the postanesthesia unit. What initial nursing activity is most important in the postoperative recovery area?

Maintain patient safety.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

Manual resuscitation bag

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury

Although nurse practice acts may vary state by state, all recognize several basic principles supporting the legal parameters for all registered nurses. Select the activity that falls under the scope of nursing practice.

Appraising and enhancing an individual's health-seeking perspective

The nurse is caring for a client with an ileal conduit is created after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care?

Application of an ostomy pouch

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse

Assesses the client's tracheostomy and lung sounds every 15 minutes

Following a cystoscopy, the client has a nursing diagnosis of acute pain related to the trauma of the procedure to the urinary tract. An appropriate nursing intervention is to:

Assist with warm sitz baths.

A nurse is conducting a health history on a patient who is seeing her health care provider for symptoms consistent with a UTI. The nurse understands that the most common route of infection is which of the following?

By ascending infection (transurethral)

The nurse is caring for a patient diagnosed with pericarditis. What serious complication should this patient be monitored for?

Cardiac tamponade

The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system?

Cardiovascular system

You are a nurse in the Emergency Department (ED) caring for a client presenting with vasodilation. Your assessment indicates that the client's central blood flow is reduced and their peripheral vascular area is hypervolemic. You notify the physician that this client is in what kind of shock?

Circulatory (distributive)

The nurse identifies a nursing diagnosis of self-care deficit, bathing related to motor impairment and decreased cognitive function for a client with cerebral metastasis. Which outcome would the nurse most likely identify on this client's plan of care?

Client participates in daily hygiene activities with assistive devices.

The nurse is caring for a pregnant patient with pregnancy-induced hypertension. When assessing the reflexes in the ankle, the nurse observes rhythmic contractions of the muscle when dorsiflexing the foot. What would the nurse document this finding as?

Clonus

A patient is suspected to have diverticulosis without symptoms of diverticulitis. What diagnostic test does the nurse anticipate educating the patient about prior to scheduling?

Colonoscopy

A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following?

Computed tomography angiography (CTA)

A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. The client's temperature is 99.8° F (37.7° C). The client's blood pressure is 104/68 mm Hg. The client's pulse rate is 76 beats/minute. The nurse detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?

Contact the health care provider and report the findings.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse

Continues assessing the client's respiratory status frequently

The LPN is collaborating with the RN in developing a plan of care for a new client. Which description of nursing roles best describes the LPN's contribution to the plan?

Data gathering, identification of client strengths, and assurance of client safety during the assessment phase

Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis?

Decreased cardiac output

A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of:

Deficient knowledge (treatment regimen).

The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication?

Diuretics

The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease?

Drugs administered may cause a wide variety of adverse effects

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

Encourage increased fluid intake.

A nurse prepares a client for a bone marrow biopsy who is suspected of having acute myeloid leukemia. What results from the bone marrow biopsy does the nurse expect?

Excess of immature leukocytes

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?

Flail chest

The nurse notes that the client's left great toe deviates laterally. This finding would be recognized as which condition?

Hallux valgus

The nurse observes a client's fingernails have a concave shape. What laboratory studies should the nurse review?

Hemoglobin and hematocrit

The nurse is monitoring a patient who sustained an open fracture of the left hip. What type of shock should the nurse be aware can occur with this type of injury?

Hypovolemic

Which element is involved in the planning phase of the nursing process?

Identify measurable outcomes

A client is being discharged from the hospital after being diagnosed with and treated for systemic lupus erythematosus (SLE). What would the nurse not say when teaching the client and family information about managing the disease?

If you have problems with a medication, you may stop it until your next physician visit.

The nurse identifies which of the following as an age-related change in the respiratory system?

Increased residual lung volume

The assessment of a client admitted with increased ascites related to cirrhosis reveals the following: pulse 86 beats per minute and weak, respirations 28 breaths per minute, blood pressure 130/88 mm Hg, and pulse oximetry 90%. Which nursing diagnosis should receive top priority?

Ineffective breathing pattern

The client with chronic open-angle glaucoma is receiving timolol eye drops. Which evaluation finding would indicate to the nurse the treatment is working?

Intraocular pressure 15 mm Hg

A patient is 2 days postoperative after having a permanent pacemaker inserted. The nurse observes that the patient is having continuous hiccups as the patient states, "I thought this was normal." What does the nurse understand is occurring with this patient?

Lead wire dislodgement

Using the assessment technique depicted in the accompanying photo, the examiner would assess which of the following structures?

Liver

While reviewing a client's records, the nurse notes a reduction in weight of 15 pounds over the last month without dieting. What factor may be associated with this possible nutritional deficit?

Losing a spouse and only child in an accident 2 months ago

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

Loss of 2.2 lb (1 kg) in 24 hours

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following?

Lungs are clear on auscultation.

A female client who reports recurring headaches, accompanied by increased irritability, photophobia, and fatigue is asked to track the headache symptoms and occurrence on a calendar log. Which is the best nursing rationale for this action?

Migraines often coincide with menstrual cycle.

The nurse is caring for a client with a cystoscopy tube draining urine from the bladder. When reviewing the client's history prior to administering care, which is of most concern?

New diagnosis of urosepsis

The nurse assesses a client after total right hip arthroplasty and observes a shortening of the extremity. The client reports severe pain in the right side of the groin. What is the priority action of the nurse?

Notify the health care provider.

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Notify the physician.

When preparing a client for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?

Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix.

Hyperresonance is audible when which area is percussed?

Overinflated lung tissue

The nurse is preparing a discharge teaching plan for a client who has had a prostatectomy. Which of the following would be appropriate to include?

Performing perineal exercises frequently throughout the day

A client with a diagnosis of acute appendicitis is awaiting surgical intervention. The nurse listens to bowel sounds and hears none and observes that the abdomen is rigid and board-like. What complication does the nurse determine may be occurring at this time?

Peritonitis

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak.

A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which strategy should the nurse use to assist the client?

Provide the client with an irrigating solution of baking soda and warm water.

A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously?

Regular

The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position?

Sitting on the edge of the bed

A client who has sustained a head injury to the parietal lobe cannot identify a familiar object by touch. The nurse knows that this deficit is which of the following?

Tactile agnosia

The nurse is revising a client's plan of care. What is an example of an expected client outcome?

The client will have the ability to climb a flight of stairs without experiencing difficulty in breathing.

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication?

The tissues give a crackling sensation when palpated.

You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult?

Tolerance

When a female client reports a frothy, yellow-green vaginal discharge, the nurse suspects the client has a vaginal infection caused by which organism?

Trichomonas vaginalis

A client has been admitted to the hospital with a large sacral pressure ulcer. The physician prescribes the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this client?

Turn the client every 2 hours.

The most frequent reason for admission to skilled care facilities includes which of the following?

Urinary incontinence

The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer?

Valsartan (Diovan)

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?

Wheezes

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided and left-sided heart failure?

ascites

The nurse is developing a client's care plan. What activity best exemplifies the assessment phase of the nursing process?

determines the client has a pulse rate of 88 bpm

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms?

impaired cerebral circulation

It is important for the nurse to provide required information and appropriate explanations of diagnostic procedures to clients with respiratory disorders in order to

manage decreased energy levels.

The nurse is developing a care plan. At which step of the nursing process will the nurse order the primary interventions to achieve a goal?

planning

A client who is going to have surgery is slightly nervous. What nursing intervention is most important for the nurse to perform?

provide education

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every

shift