Prep U - Ch 14 : Nursing Process

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action?

Collaborate with other disciplines to plan end-of-life care for the client.

Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action?

Collaborate with other disciplines to revise the discharge plans.

While implementing the plan of care for a client, the nurse uses interpersonal skills. Which of the following would the nurse most likely use?

Communication is a key interpersonal skill to carry out interventions. Decision making, problem solving and teaching are intellectual skills.

Which action is appropriate when evaluating a patient's responses to a plan of care?

Continue the plan of care if more time is needed to achieve the goals/outcomes.

The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the nursing students indicates further education is required?

"Nursing interventions must be approved by other members of the health care team."

When the nurse is administering medication, an elderly client states, "Why does everyone keep asking my name? I've been here for days." How should the nurse respond to the client?

"We ask your name to ensure that we are treating the right client."

An elderly patient with a diagnosis of pneumonia is producing large amounts of secretions with his cough and is occasionally gurgling when he breaths. The nurse has responded by increasing the height of the patient's bed and suctioning the patient's mouth. The nurse has most likely performed which of the following?

An independent nursing action.

The nurse is caring for a client admitted to the hospital for renal calculi. What is the best action to take first?

Assess for bladder distention.

One hour after receiving pain medication, a postoperative client complains of intense pain. What is the nurse's most appropriate first action?

Assess the client to determine the cause of the pain.

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.

The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention?

Assess the client's response to the ambulation.

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do?

Delay the instruction until the visitors leave.

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action?

Discontinue the teaching and attempt the teaching at another time.

A female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside where staff and other clients can hear her. The nurse should respond by modifying which of the following resources?

Environment

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem?

Investigate the circumstances that contributed to client falls

As the nurse bathes a patient, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important?

It enables the nurse to revise the care plan appropriately.

The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem?

Making changes in the plan of care based upon assessment data

The physician has ordered that the client should ambulate three times a day. The nurse enters the room to ambulate the client and the client complains of pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

Nurse case manager

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

Nurses

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

Quality assurance

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action?

Reassess the appropriateness of the method of instruction.

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action?

Revise the care plan to allow the client to ambulate to the bathroom independently.

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. In order to promote the health of the family members, what would be the most important information for the nurse to include?

Risk factors and prevention of diabetes mellitus

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

The client is able to explain when and why he needs to check his blood sugar.

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.

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

The nurse and client measure achievement of planned outcomes of care. In evaluating, which is the fifth step of the nursing process, the nurse and client together measure how well the client has achieved the outcomes specified in the plan of care.

A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse?

The nurse transfers responsibility but is accountable for the outcome.

Why are quality-assurance programs important in nursing?

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

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

According to the American Nurses Association, who determines the scope of nursing practice?

nurses According to the American Nurses Association, it is the nursing profession that determines the scope of nursing practice.

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?

Discuss possible alternatives to a blood transfusion with the physician.

The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What is the nurse's next action?

Document the effectiveness of the intervention.

The surgeon is insisting that a client consent to a hysterectomy. The client says that she will not make a decision without her husband's consent. What is the nurse's best course of action?

Ask the surgeon to wait until the client has had a chance to talk to her husband.

A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this?

Cognitive Cognitive goals involve increasing client knowledge. These goals may be evaluated by asking clients to repeat information or to apply new knowledge in their everyday lives.

The nurse is caring for a client who is recovering from a CVA (cerebrovascular accident). When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client while another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?

Communicate with the physicians to coordinate their orders.

A nurse caring for an elderly patient who has dementia observes another nurse putting restraints on the patient without a physician's order. The patient is agitated and not cooperating. What would be the best initial action of the first nurse in this situation?

Confront the nurse and explain how this could be dangerous for the patient.

The nurse is preparing to give the client a bath early in the morning. The client states, "I prefer to take my bath at night. It helps me sleep." What is the nurse's most appropriate action?

Reschedule the client's bath to the evening shift.

A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care?

To be sure the intervention is safe