PrepU Nursing Process

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The nurse is most likely to collect timely, specific information by asking which of the following questions? A. "Would you describe what you are feeling?" B. "How are you today?" C. "What would you like to talk about?" D. "Where does it hurt?"

A. "Would you describe what you are feeling?" Rationale: This is an open-ended question that will elicit subjective data. The data collected will reflect the client's current health status and human response(s) and should generate specific information that can be used to identify actual and/or potential health problems. Options 2 and 3 are more likely to elicit general, nonspecific information. Option 4 may result in a brief, one-word response or nonverbal gesture indicating the site of the client's pain. A better approach to collect specific information might be, "Describe any pain you are having."

Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. A. Admitting not knowing how to do a procedure and requesting help B. Using clever and persuasive remarks to support an opinion or position C. Accepting without question the values acquired in nursing school D. Finding a quick and logical answer, even to complex questions E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs.

A. Admitting not knowing how to do a procedure and requesting help E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs. Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making clear what they do not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical thinking.

The nurse assigned to care for a postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? A. Assess the client to be sure ambulation with assistance is an appropriate care measure B. Ask the client if he or she is ready to ambulate C. Ask whether the UAP has time to assist the client D. Ask the charge nurse whether UAPs have ambulated the client during this shift

A. Assess the client to be sure ambulation with assistance is an appropriate care measure Rationale: Prior to delegating any client care responsibilities, the nurse must assess the client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4 would not constitute an assessment of the client's current status.

A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation

A. Assessment Rationale: The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data.

The nurse decides it would be beneficial to the client to allow the client's infant granddaughter to visit before the client's scheduled heart transplant. Before implementing this intervention the nurse should collaborate with which of the following? Select all that apply. A. Client and Family B. Other nursing staff on the unit C. Security department D. Hospital administration E. This is not a collaborative intervention so no collaboration will be needed prior to implementation

A. Client and Family B. Other nursing staff on the unit Rationale: Collaboration with the client and family will encourage a sense of autonomy and active involvement in the healthcare process for the client. In this case collaboration with other nursing staff will ensure the successful implementation of the planned intervention. There is no real need for collaboration with hospital administration or the security department in this situation although the nurse should be aware of her responsibility to collaborate at those levels when the situation demands it.

The nurse would make which of the following inferences after performing the appropriate client assessment? A. Client is hypotensive B. Respiratory rate of 20 breaths per minute C. Oxygen saturation of 95% D. Client relays anxiety about blood work

A. Client is hypotensive Rationale: An inference is the nurse's judgment or interpretation of cues such as judging a blood pressure to be lower than normal. A cue is any piece of data information that influences a decision. Options 2, 3, and 4 are cues that could lead to inferences.

When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards B. Compare the reading with one taken in the opposite arm C. Determine gaps in the vital signs in the client record D. Compare the current measurement with previous ones

A. Compare this reading against defined Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older adult. The nurse compares the client's data against identified standards to determine whether this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to previous ones (option 4) will give additional client data, but the comparison alone will not determine whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current measurement.

The nurse notes that the client often sighs and says in a monotone voice, "I'm never going to get over this." When encouraged to participate in care, the client says, "I don't have the energy." The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply. A. Hopelessness B. Powerlessness C. Interrupted sleep pattern D. Disturbed self esteem E. Self care deficit

A. Hopelessness B. Powerlessness Rationale: Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5).

The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following? A. Incomplete data B. Generalize from experience C. Identifying with the client D. Lack of clinical experience

A. Incomplete data Rationale: To collect data accurately, the client must actively participate. Incomplete data can lead to inappropriate nursing diagnosis and planning. The other options are not relevant to the question as presented.

During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?" A. Introduction B. Body C. Closing D. Orientation

A. Introduction Rationale: Asking about the weather initiates the social or introductory phase of the interview and allows the nurse to begin an assessment of the client's mental status. The goal is to develop rapport with the client at the beginning of the interview. In the body the client responds to the nurse's questions. During the closing the nurse or the client terminates the interview.

After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods? A. Return demonstration B. Explanation C. Achievement of 90 on written test D. Have client explain produce to the family

A. Return demonstration Rationale: Interpersonal skills are the sum of the activities the nurse uses when communicating with others. Technical/psychomotor skills are "hands-on" skills, which are often procedures and are evaluated by return demonstration. Cognitive skills are the intellectual skills of analysis and problem-solving and are evaluated by tests.

The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source B. Subjective data from a secondary source C. Objective data from a primary source D. Objective data from a secondary source

A. Subjective data from a primary source Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source?

Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)? A. Taking vital signs of clients on the nursing unit B. Assisting the physician with an invasive procedure C. Adjusting the rate on an infusion pump D. Evaluating achievement of client outcome goals

A. Taking vital signs of clients on the nursing unit Rationale: Part of the professional nurse's role is to delegate responsibility for activities while maintaining accountability. The nurse must match the needs of the client with the skills and knowledge of UAPs. Certain skills and activities, such as those in options 2, 3, and 4, are not within the legal scope of practice for a UAP.

Which of these is a correctly stated outcome goal written by the nurse? A. The client will walk 2 miles daily by March 19 B. The client will understand how to give insulin by discharge C. The client will regain their former state of health by April 1 D. The client achieve desired mobility by May 7

A. The client will walk 2 miles daily by March 19 Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option 1 is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19).

The nurse should avoid asking the client which of the following leading questions during a client interview? A. "What medication do you take at home?" B. "You are really excited about the plastic surgery, aren't you?" C. "Were you aware I've has this same type of surgery?" D. "What would you like to talk about?"

B. "You are really excited about the plastic surgery, aren't you?" Rationale: A leading question directs the client's answer. The phrasing of the question indicates an expected answer. The client may be influenced by the nurse's expectations and may give inaccurate responses. This process can result in an error in diagnostic reasoning.

The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply. A. Collect and organize client information B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses E. Develop client goals

B. Analyze data C. Identify problems, risk, and client strengths D. Develop nursing diagnoses Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase.

Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis? A. Grimacing B. Anxiety C. Oxygenation saturation 93% D. Output 500 mL in 8 hours

B. Anxiety Rationale: The problem part of a nursing diagnosis should state the client's response to a life process, event, or stressor. These are categorized as nursing diagnoses. The incorrect options are cues the nurse would use to formulate the nursing diagnostic statement.

The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight and age. The nurse should take which of the following actions? A. Administer the medication as ordered by the prescriber B. Call the prescriber to discuss the order and the nurse's concern C. Administer the medication, but chart the nurse's concern about the dosage D. Give the client half the dosage and document accordingly

B. Call the prescriber to discuss the order and the nurse's concern Rationale: Client safety is of the utmost importance when implementing any nursing intervention. If the nurse feels that an order is unsafe or inappropriate for a client, the nurse must act as a client advocate and collaborate with the appropriate healthcare team member to determine the rationale for the order and/or modify the order as necessary. A nurse accepts accountability for his or her actions. Options 1, 3, and 4 are inappropriate and unsafe.

The functional health pattern assessment data states: "Eats three meals a day and is of normal weight for height." The nurse should draw which of the following conclusions about this data? Select all that apply. A. Client has an actual health problem B. Client has a wellness diagnosis C. Collaborative health problem needs to be written D. Possible nursing diagnosis exists E. Specific questions about the diet should be asked next

B. Client has a wellness diagnosis E. Specific questions about the diet should be asked next Rationale: The description indicates a healthy pattern of nutrition for the client. A wellness diagnosis might be stated as: "Potential for enhanced nutrition." An actual health problem is a client problem that is currently present. The nurse should also do a diet assessment to determine the quality of the food eaten during meals. These actions by the nurse are within the scope of independent nursing practice and are not collaborative in nature.

The client reports nausea and constipation. Which of the following would be the priority nursing action? A. Collect a stool sample B. Complete an abnormal assessment C. Administer an anti-nausea medication D. Notify the physician

B. Complete an Abdominal assessment Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a complete assessment.

The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should: A. Formulate post-discharge nursing diagnoses B. Draw conclusion about resolution of current client problems C. Assess the client for baseline data to be used at the LTC facility D. Plan the care that is needed in the LTC facility

B. Draw conclusion about resolution of current client problems Rationale: Terminal evaluation is done to determine the client's condition at the time of discharge. This evaluation is best reflected in option 2 because it focuses on which goals were achieved and which were not. Ongoing evaluation is done while or immediately after implementing a nursing intervention. Intermittent evaluation is performed at specified intervals, such as twice a week. Items related to care post-discharge (options 2, 3, and 4) should be done on admission to the LTC facility.

The nurse would place which correctly written nursing diagnostic statement into the client's care plan? A. Cancer relater to cigarette smoking B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen saturation of 91% C. Imbalance nutrition: more than body requirement related to overweight status D. Impaired physical mobility related to generalized weakness and pain

B. Impaired gas exchange related to aspiration of foreign matter as evidence by oxygen saturation of 91% Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human response) names/labels the problem. The second part (related factors) includes the factors that either contribute to or are probable etiologies of the human response. Some formats include a third part to the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms and is joined to the statement with the label as evidenced by. This type of statement is the most complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague.

The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

B. Planning Rationale: The planning step of the nursing process involves formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a client's human response, and once a plan is established, the interventions are implemented (option 3) and evaluated (option 4).

The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulate in the hall C. Write individualized nursing orders in the care plan D. Compare client responses to the desired outcomes for pain relief

B. Record in the medical record the distance a client ambulate in the hall Rationale: The implementation phase of the nursing process involves carrying out or delegating the nursing interventions and recording nursing activities and client responses in the medical records. Option 1 represents diagnosing. Option 3 represents planning. Option 4 represents evaluation.

The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis

B. Reexamine the nursing orders Rationale: The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome.

The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan? A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours

B. Skin will remain intact and without redness during hospital stay Rationale: The human response/label is what needs to change (Risk for impaired skin integrity). The label suggests the outcomes. In this case, "skin will remain intact" is the desired outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility. Option 3 addresses pain. Option 4 is an intervention.

When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B. Suggesting the medication can be diluted in a beverage C. Asking the nurse manager about how to approach the situation D. Notifying the physician inability to give the client this medication

B. Suggesting the medication can be diluted in a beverage Rationale: Diluting the medication in a beverage may make the medication more palatable. Using critical thinking skills, the nurse should try to problem-solve in a situation such as this before asking for the assistance of the nurse manager. Suggesting an alternative method of taking the medication (provided that there are no contraindications to diluting the medication) should improve the likelihood of the client taking the medication.

Which desired outcome written by the nurse is correctly written and measurable? A. Client will have a normal bowel pattern by April 2 B. The client will lose 4 lbs. within next 2 weeks C. The nurse will provide skin care at least 3 times each day D. The client will breathe better after resting for 10 minutes

B. The client will lose 4 lbs. within next 2 weeks Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Each of the incorrect options lacks one of these required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a client goal. Option 4 does not include the level at which the behavior should be performed.

The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B. The client's urine output was 450 mL C. The client states, "I didn't see any stones in my urine." D. The client states, "I feel like I have passed a stone."

B. The client's urine output was 450 mL. Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse. The objective data is the measurement of the urine output. A client's statements and reports of symptoms are documented as subjective data, such as the data found in options 1, 3, and 4.

Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? A. Use the previous, less restrictive policy conscientiously B. Express immediate disagreement with the new policy C. Ask for the rationale behind the new policy D. Obey the policy but continue to voice disapproval of it to co-workers

C. Ask for the rationale behind the new policy Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed change and understand its purpose. Options 1, 2, and 4 represent unprofessional behavior. Option 1 also places a client's safety at risk.

Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge E. Client will be medicated every 4 hours by the nurse

C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal.

A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview? A. Help the client to get settled and do the interview the next morning when the client is rested B. Do the interview immediately, directing the majority of the questions to the client's spouse C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication

C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns Rationale: To collect data accurately, the client must participate. Attending to the client's immediate personal needs before expecting the client to focus on the interview will maximize the accuracy of the data collected. Data should be collected shortly after admission. The best source of data is the client. The management of the client's anxiety is the responsibility of the nurse conducting the interview and initiating the relationship.

A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client's progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write? A. Client understands the signs of impaired circulation B. Goal met: Client cited numbness and tingling as sign of impaired circulation C. Goal not met: Client able to name only two signs of impaired circulation D. Goal not met: Client unable to describe signs of impaired circulation

C. Goal not met: Client able to name only two signs of impaired circulation Rationale: The goal has not been met because the client states only two out of three signs of impaired circulation. By comparing the data with the expected outcomes, the nurse judges that while there has been progress toward the goal, it has not been completely met. The care plan may need to be revised or more effective teaching strategies may need to be implemented to achieve the goal.

The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time? A. Assessment B. Planning C. Implementation D. Evaluation

C. Implementation Rationale: The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. Data gathering occurs during assessment. Goal setting occurs during planning. Determining attainment of client goals occurs as part of evaluation.

In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction B. Instruct the client to make dietary changes by reducing sodium intake C. Include the client and family when setting goals and formulating the plan of care D. Assess past compliance to medication regimens

C. Include the client and family when setting goals and formulating the plan of care Rationale: In developing a plan of care, nurses engage in a partnership with the client and family. Nurses do not plan care for clients; instead they plan care with clients and families. Assessment (option 4), goal setting (option 1), and interventions (option 2) will be most accurate and effective when carried out in partnership with the client and family. The other options represent other actions to take, but they will have less overall effectiveness if the client and family are not part of the plan.

The nurse overhears an unlicensed assistive person (UAP) who has just been accepted to nursing school say to a client, "You must be so pleased with your progress." The nurse later explains to the UAP that this is an example of what type of question? A. Close-ended question B. Open-ended question C. Leading question D. Neutral question

C. Leading question Rationale: A leading question is asked in a way that suggests the type of answer that is expected. This can result in inaccurate data collection. A closed-ended question generally requires only a "yes" or "no" or short factual answer. Open-ended questions encourage clients to elaborate on their thoughts and feelings. Neutral questions do not influence the client's answer.

The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein intake C. Risk for impaired skin integrity related to malnutrition D. Impaired nutrition related to current illness

C. Risk for impaired skin integrity related to malnutrition Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or less than body requirements) and is therefore incomplete. It also does not provide direction for development of goals and interventions.

The nurse needs to validate which of the following statements pertaining to an assigned client? A. The client has a hard, raised, red lesion on his right hand. B. A weight of 185 lbs. is recorded in the chart C. The client reported an infected toe D. The client's blood pressure is 124/70. It was 118/68 yesterday.

C. The client reported an infected tow Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse should assess the client's toe to validate the statement.

Which nurse is demonstrating the assessment phase of the nursing process? A.The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals

C. The nurse who ask the client how much lunch he or she ate Rationale: Assessment involves collecting, organizing, validating, and documenting data about a client. Option 1 represents the evaluation phase. Option 2 represents the implemention phase. Option 4 represents the planning phase.

A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis? "By discharge, the client correctly identifies three potassium-rich food sources." "Before discharge, the client knows which food sources are high in potassium." "The client understands all complications of the disease process." "The client knows the importance of consuming potassium-rich foods daily."

Correct response: "By discharge, the client correctly identifies three potassium-rich food sources." Explanation: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behavior. The nurse should express that behavior in terms of client expectations and should indicate a time frame in which to accomplish it. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable outcomes. Understanding all complications of a disease process isn't measurable or specific to the nursing diagnosis listed.

The nurse's responsibility concerning informed consent is reflected in which client statement? "If I am declared mentally incompetent, I can give informed consent if I am in the hospital under a mental health regulatory law." "I must be fully informed about treatments, tests, alternative treatments, and the risks and benefits of each." "The healthcare provider and the nurse must each obtain informed consent from me." "My 14-year-old child may give informed consent to all medical and nursing procedures without my consent."

Correct response: "I must be fully informed about treatments, tests, alternative treatments, and the risks and benefits of each." Explanation: Before informed consent is given, the physician performing the procedure must tell the client about the treatment, tests, alternative treatments, and the risks and benefits of each. A professional nurse involved in the informed consent process witnesses the consent and does not actually obtain the consent. The physician is responsible for obtaining consent. Only a minor who is married or emancipated may give informed consent. A client must be mentally competent to legally give informed consent for procedures.

A nurse manager overhears a nurse caring for a client with an I.V. make this statement: "If you don't stop playing with your I.V., I will tie your hand to the side rail." What is the most appropriate response by the nurse manager to address this situation? "You will save the client from another I.V. insertion by restraining the client's hand." "You need to think of a more creative way to stop the client from playing with the I.V." "I need to inform you that your behavior is within the definition of assault." "I'm sure the client knows you were joking, but it was still inappropriate to say."

Correct response: "I need to inform you that your behavior is within the definition of assault." Explanation: The nurse's response is threatening and could legally be interpreted as assault. The manager must intervene in the best interest of the client and take the opportunity to educate the nurse regarding the comments and potential actions. The other options do not represent appropriate interventions for the scenario described.

A nurse is caring for a client who is receiving hospice care at home. The client's neighbors have been calling the nurse to inquire about the client's condition. What should the nurse tell the neighbors? "The client is in a coma now." "Please call the client's sister" "Please call the oncologist." "The client is not expected to live much longer."

Correct response: "Please call the client's sister" Explanation: The family is in the best position to give the information they elect to disclose to friends and community members. The hospice nurse and the oncologist must maintain client confidentiality and follow privacy guidelines for release of confidential information. Therefore, disclosing any information about the client's condition would be inappropriate.

The nurse is instructing the unlicensed assistive personnel (UAP) on how to position the wheelchair to assist a client with left-sided weakness transfer from the bed to a wheelchair using a transfer belt. Which statement by the UAP tells the nurse that the UAP has understood the instructions for placing the wheelchair? "I'll place the wheelchair behind the client." "The wheelchair should be placed on the right side of the bed." "As long as I assist the client with the belt, it doesn't matter where the wheelchair goes." "The wheelchair should be placed at the head of the bed."

Correct response: "The wheelchair should be placed on the right side of the bed." Explanation: When assisting a client with a weakness out of bed, it is important that the client always move toward the stronger side. This allows the client to assist in the move as much as possible. In this case, the client will need to move toward the right side of the bed to maximize the use of the strong arm and leg. Placing the wheelchair at the head of the bed or behind the client does not allow for a safe transfer of the client. The transfer belt is used to help the client balance and provide safety, not to lift the client; the transfer should be made with the least amount of work for both the client and the UAP while ensuring the safety of the client.

A client who has type 1 diabetes is being prepared to have a craniotomy to remove a tumor. The nurse is evaluating the client's understanding of the informed consent before witnessing the client's signature on the operative consent form. Which statement from the client indicates that the nurse needs to contact the surgeon for further communication with the client? "I will die if the tumor is not removed from my brain." "There are no major risks from this surgery." "The surgeon explained how the craniotomy was done." "We talked about the effect of my diabetes on healing."

Correct response: "There are no major risks from this surgery." Explanation: There are risks with both the surgical procedure and the general anesthesia required for a craniotomy. The risks involved in the procedure are a part of the informed consent. Therefore, if the client states a belief that there are no major risks from a craniotomy, the health care provider needs to provide further teaching. Other information that is part of an informed consent includes potential complications, expected benefits, inability of the surgeon to predict results, irreversibility of the procedure (if applicable), and other available treatments. Talking about the effects of the diabetes on healing, explaining how the craniotomy is performed, and explaining the consequences of declining treatment (e.g., death if the tumor is not removed) represent appropriate actions to provide information to the client.

The nurse is performing discharge teaching for a client who experienced a recent heart attack. The client reports feeling excited and ready to go home and "get on with life." What response by the nurse is most appropriate? "Do you recall the teaching done by the physiotherapist related to your heart attack?" "What are your plans for when you get home and back to getting on with your life?" "You sound excited to be recovering from your heart attack! A positive attitude is important" "While I am happy you are going home, your lifestyle will have to change considerably."

Correct response: "What are your plans for when you get home and back to getting on with your life?" Explanation: When preparing the client for discharge, the nurse investigates the client's understanding of the teaching and readiness for discharge by asking open-ended questions when possible. Closed questions such as "do you remember" could result in a "yes" response. Instead, the nurse reframes the client's comment while gathering more information about what activities may be planned and engages the client further depending on the response. The nurse should not lecture the client about lifestyle changes or simply praise the client for having a positive attitude.

The nurse is performing discharge teaching for a client who experienced a recent heart attack. The client reports feeling excited and ready to go home and "get on with life." What response by the nurse is most appropriate? "While I am happy you are going home, your lifestyle will have to change considerably." "What are your plans for when you get home and back to getting on with your life?" "You sound excited to be recovering from your heart attack! A positive attitude is important" "Do you recall the teaching done by the physiotherapist related to your heart attack?"

A nurse in a rural community completed a workshop on traditional Chinese culture and how to incorporate traditional Chinese values into one's healthcare practice. One nurse notes caring for a client with Chinese heritage who did not act the way the nurse would anticipate based on the workshop. The nurse asks why the client's behavior differs from what is being taught. What is the most appropriate response by the presenter? "It is possible that your client did not grow up with a strong tie to cultural roots." "You have to remember that not all members of a culture share identical beliefs." "Many clients of other cultural backgrounds try to fit in with Western culture so they get equal treatment." "Clients behave in different ways depending on their health conditions."

Correct response: "You have to remember that not all members of a culture share identical beliefs." Explanation: The nurse is assuming that all members of a culture behave in a manner that reflects the same values and beliefs. This is not accurate and relies on stereotyping. Regardless of a client's diagnoses or health concerns, cultural practices will vary within groups. The upbringing of the client will influence cultural practices and preferences, but this is not the only factor that results in variation between people within a specific culture. Stating the client is trying to "fit in" is an assumption and should not be stated as a factor unless the nurse has assessed this to be true for this specific client. In a culturally safe environment, clients do not have to try to fit in.

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? "Could you clarify for me whether you were joking with the client?" "I will have to report you for unprofessional behavior toward a client." "I think you need to review therapeutic communication techniques." "Your verbal threats to the client are legally considered assault."

Correct response: "Your verbal threats to the client are legally considered assault." Explanation: Assault is conduct that makes a person fearful and produces a reasonable apprehension of harm. The nurse's behavior in legal terms is assault.

A bedridden client is scheduled to receive subcutaneous injections of heparin at 8:00 a.m. and 8:00 p.m. each day. The client's medication administration record would present these times as 800 and 2200 0800 and 2200 0800 and 1200 0800 and 2000

Correct response: 0800 and 2000 Explanation: 8:00 a.m. is 0800 in military time and 8:00 p.m. is 2000.

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

Correct response: Ask the manager to find an interpreter who is able to provide the discharge instructions. Explanation: The best option would be for an interpreter to provide translation and for the nurse to document the health teaching and discharge instructions. The two can work together to provide the instructions verbally and in writing and answer the client's questions. There is no means for the English-speaking nurse to know whether the grandchild has translated the information accurately and whether the information was understood. The other option does not provide for competent nursing care.

The nurse is unable to find the health record (chart) for a client who has arrived for a clinic visit. Which is the best action by the nurse? Advise the client that the appointment will have to be rescheduled due to the fact that the medical record cannot be located. Document the information about the visit on paper, and transcribe these notes into the client's medical record once it is located. Call one of the client's other healthcare providers to request that a copy of the medical records for the client be sent to the clinic. Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later.

Correct response: Begin a new medical record with all client identifiers to document the current visit and merge this document into the medical record later. Explanation: Documentation is an essential and legal component of providing care to clients. Information must be documented as it is collected. The nurse should not send the client away without the client getting the care that was to be provided. Therefore, the nurse creates a new record that contains all the client's appropriate identifiers so this can be added to the client's primary medical record when it is located. The nurse should be truthful about the missing records and should avoid transcribing notes whenever possible to avoid data errors. Another healthcare provider's records are not a substitute for the health record specific to this clinic. Requesting records from another provider would only be appropriate if relevant to the client's current reason for the visit and if the client consented to the transfer of this information.

An unlicensed nursing personnel (UAP) recorded a client's 0600 blood glucose level as 126 mg/dL (7 mmol/L) instead of 216 mg/dL (12 mmol/L). The UAP did not recognize the error until 0900 but reported it to the nurse right away. What should the nurse do first? Wait and observe the client for symptoms of hyperglycemia. Call the health care provider (HCP). Reprimand the UAP for the error. Complete an incident report.

Correct response: Call the health care provider (HCP). Explanation: The error should be reported to the HCP promptly; the HCP may write additional prescriptions. The nurse should complete an incident report because a potentially dangerous event happened during the client's care. The nurse should observe the client for symptoms of hyperglycemia but first must call the HCP and complete an incident report. The UAP does not need to be reassigned for this error. The nurse does not need to reprimand the UAP for the error because the UAP already knows an error was made and has reported it to the nurse.

Client 1: 1300 - After lunch toileting Client 2: 1300 - Dressing change to left heel wound Client 3: 1300 - Intravenous piggyback (100 cc) every 6 hours Client 4: 1300 - Soonest time for requested post-operative pain medication The nurse is reviewing this worksheet with the unlicensed assistive personnel (UAP) when prioritizing afternoon nursing care. What is the priority order for the nurse's administration of client care at 1300 hours? Client 4, Client 3, Client 2, Client 1 Client 2, Client 1, Client 3, Client 4 Client 3, Client 1, Client 2, Client 4 Client 4, Client 1, Client 3, Client 2

Correct response: Client 4, Client 3, Client 2, Client 1 Explanation: It is important for the nurse to prioritize care in an efficient manner. The highest priority for the afternoon is administering requested pain medication for a postoperative client. Next, the intravenous piggyback would be initiated; the wound dressing could be changed while the IV is infusing. A client on a toileting schedule would be taken to the restroom as the last priority; this task that could also be delegated.

The nurse-manager on the oncology unit wants to improve documentation of the effectiveness of analgesia medication within 30 minutes after administration. What should the nurse-manager do first? Change the policy of documentation to 45 minutes. Consult the pharmacist. Consult the nurses on the evening shift where documentation of analgesia is the greatest problem. Complete a brief quality improvement study and chart audit to document the rate of adherence to the policy and the pattern of documentation over shifts.

Correct response: Complete a brief quality improvement study and chart audit to document the rate of adherence to the policy and the pattern of documentation over shifts. Explanation: To determine the cause of this problem, a quality improvement study should be conducted along with a chart audit. Before implementing solutions to a problem, the precise issues in the hospital system must be observed and documented. Changing the time to chart from 30 minutes to 45 minutes does not solve the problem. It is not the pharmacist's role to provide consultation about documentation of drugs administered by nurses. Consulting the evening nurses may be helpful, but this is a systems issue of the entire unit and involves every registered nurse (RN) administering analgesia.

The nurse-manager on a gynecologic surgical unit is addressing reports from clients that they have to wait too long on the night shift for their pain medication. Which course of action should the nurse-manager take first? Change the staffing schedule on nights to include a medication nurse. Consult the nursing supervisor. Complete a quality improvement study with the night nurses to document the waiting times for pain medication and other data, including staffing and patient acuity. Consult the nurses on the evening shift about their evaluation of the night nurses regarding these concerns.

Correct response: Complete a quality improvement study with the night nurses to document the waiting times for pain medication and other data, including staffing and patient acuity. Explanation: To determine the cause of this problem, a quality improvement study should be conducted. Before implementing solutions to a problem, the precise issues in the hospital system must be observed and documented. Consulting with the evening nurses may result in biased observations because the evening nurses are not conducting care under the same environment as the night nurses. Including a medication nurse is not the first step in understanding the problem and may be an unrealistic or expensive solution. The supervisor is not directly involved with the problem and should only be consulted if the problem cannot be solved by those involved.

A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate? Re-zero the equipment and take another reading. Call the physician and obtain an order for a fluid bolus. Continue to monitor the client as ordered. Call the physician and obtain an order for a diuretic.

Correct response: Continue to monitor the client as ordered. Explanation: Normal CVP ranges from 3 to 7 mm Hg. The nurse doesn't need to take any action other than to monitor the client. It isn't necessary to re-zero the equipment. Calling a physician and obtaining an order for a fluid bolus would be an appropriate intervention if the client has a CVP less than 3 mm Hg. Administering a diuretic would be appropriate if the client had excess fluid, as demonstrated by a CVP greater than 7 mm Hg.

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? Describe each of the potential causes and possible treatment modalities. Discuss alternative methods of having a family, such as adoption. Choose an appropriate infertility treatment method. Acknowledge that only 50% of infertile couples achieve a pregnancy.

Correct response: Describe each of the potential causes and possible treatment modalities. Explanation: By the end of the first visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evaluation shows that a treatment or procedure may help them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be difficult, painful, or risky. The first visit is not the appropriate time to decide on a treatment plan because the couple needs time to adjust to the diagnosis of infertility, a crisis for most couples. Although the couple may be in a hurry for definitive therapy, a thorough assessment of both partners is necessary before a treatment plan can be initiated. The success rate for achieving a pregnancy depends on both the cause and the effectiveness of the treatment, and in some cases it may be only as high as 30%. The couple may desire information about alternatives to treatment, but insufficient data are available to suggest that a specific treatment modality may not be successful. Suggesting that the couple consider adoption at this time may inappropriately imply that the couple has no other choice. If a specific therapy may result in a pregnancy, the couple should have time to consider their options. After a thorough evaluation, adoption may be considered by the couple as an alternative to the costly, time-consuming, and sometimes painful treatments for infertility.

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? Discuss alternative methods of having a family, such as adoption. Choose an appropriate infertility treatment method. Acknowledge that only 50% of infertile couples achieve a pregnancy. Describe each of the potential causes and possible treatment modalities.

When maintaining medical records for a client, the nurse knows that a medical record also serves as legally admissible evidence. What should the nurse do to ensure legally defensible charting? Use abbreviations wherever possible. Ensure that the client's name appears on all pages. Record all facts and subjective interpretations. Leave spaces between entries and signature.

Correct response: Ensure that the client's name appears on all pages. Explanation: The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and not use abbreviations wherever possible. The nurse should record all facts but not any subjective interpretations to ensure that the document is legal evidence.

A public health nurse is working in a community immunization clinic. Client information gathered at the clinic is stored and transported to the health unit on a portable memory device. Which action must the nurse take to protect the confidentiality of the information? Lock the memory device at all times. Have a backup copy on a portable computer. Make sure the nurse's computer is password protected. Ensure that the information on the memory device is protected.

Correct response: Ensure that the information on the memory device is protected. Explanation: The only way to ensure the information remains confidential is to encrypt it. The other options do not provide enough security if the device is lost or stolen. Passwords can be bypassed and the device can be stolen even from a locked area.

The child of an alert and oriented elderly client asks what parent's most recent blood glucose level was. What is the nurse's best response? Have the child sign a "Disclosure of Health Information" form prior to giving the child the information. Tell the client's child the blood glucose level because this test is performed on the nursing unit. Explain that this information cannot be disclosed without the client's permission. Ask the client's child if she has her parent's permission to access the parent's health information.

Correct response: Explain that this information cannot be disclosed without the client's permission. Explanation: The Health Insurance Portability and Accountability Act in the United States, and the Canadian Privacy Act and the Personal Information Protection and Electronic Documents Act (and often provincial/territorial legislation) prevents family members or friends from acquiring health information without consent of the client involved. Whether the test was performed on the nursing unit or others had given the client's child this information is irrelevant; the client's test results are still protected health information. The nurse should not ask the client's child if the child has permission, the client should be asked. If a disclosure of health information form is signed, it should be the client signing, not the daughter. (Note: the caregiver of a client who is incapacitated CAN be given healthcare information.)

The child of an alert and oriented elderly client asks what parent's most recent blood glucose level was. What is the nurse's best response? Tell the client's child the blood glucose level because this test is performed on the nursing unit. Explain that this information cannot be disclosed without the client's permission. Have the child sign a "Disclosure of Health Information" form prior to giving the child the information. Ask the client's child if she has her parent's permission to access the parent's health information.

A newly admitted client in a skilled nursing facility has diabetes and is experiencing episodes of hypoglycemia. Place in the order the manner in which the nurse should provide evening care to the resident. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Assess percentage of the meal eaten. 2Administer 20 units of insulin aspart. 3Identify the client using two identifiers. 4Assess the client's blood glucose level. 5Provide an evening snack. 6Provide an evening meal.

Correct response: Identify the client using two identifiers. Assess the client's blood glucose level. Provide an evening meal. Assess percentage of the meal eaten. Administer 20 units of insulin aspart. Provide an evening snack. Explanation: The order for the nurse to follow is to first identify the client using two identifiers, assess the client's blood glucose level, provide the client with an evening meal, assess the percentage of the meal the client has eaten, administer 20 units of insulin aspart, and provide an evening snack. This order will include assessments and prevent administering insulin if resident does not eat.

The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month, five clients were diagnosed with pressure ulcers. What should the nurse manager do? Ask the staff education department to conduct an educational session about preventing pressure ulcers. Conduct a chart audit to determine which nurses on which shifts were giving nursing care to the clients with pressure ulcers. Use benchmarking procedures to compare the findings with other nursing units in the hospital. Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes.

Correct response: Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes. Explanation: The problem of pressure ulcers in hospitalized clients is best addressed by using quality improvement techniques to identify the problem, determining strategies for improvement, and setting goals for outcomes. Benchmarking for comparison will indicate where this nursing unit compares with other units, but does not address the problem for this unit; having clients with pressure ulcers on any unit is not acceptable. Educational programs are more effective after there is an understanding of the problem. Chart audits and blaming do not solve the problem or address quality improvement measures.

A family member of a resident in a long-term care facility reports to the nurse that her mother's diamond ring is missing. Another resident reported a day earlier that a twenty-dollar bill was missing from his/her night table. What should the nurse do in this situation? Remind the residents and family members not to leave valuables unattended. Notify the supervisor and call the police. Pass the information on to the doctor and the next shift staff. Report the incidents to the facility's lawyer.

Correct response: Notify the supervisor and call the police. Explanation: The supervisor should be made aware of the situation and the police should be called to investigate the potential theft. The other answers do not advocate for the clients and their families. It is the responsibility of the nurse to take action because the nurse was the person to receive the information. This is known as due diligence.

Which measure should a home healthcare nurse implement to minimize the potential for lawsuits? Have the client sign a waiver prior to the entry phase of a visit. Apply more conservative interventions than those used in a hospital setting. Perform thorough, accurate, and timely documentation. Integrate the client's learning needs and goals into plans of care.

Correct response: Perform thorough, accurate, and timely documentation. Explanation: The need for thorough documentation is especially high in home healthcare settings, both to ensure continuity of care and to provide a legally acceptable record of what occurred during nurse-client interactions. The nurse should not implement more conservative interventions solely to minimize liability, and a waiver of rights is not a component of home healthcare. The client's learning needs and goals should indeed by integrated into plans of care but this action does not protect against lawsuits.

The nurse discusses with the parents how best to raise the IQ of their child with Down syndrome. Which intervention would be most appropriate? Let the child play with more able children. Serve hearty, nutritious meals. Provide stimulating, nonthreatening life experiences. Give vasodilator medications as prescribed.

Correct response: Provide stimulating, nonthreatening life experiences. Explanation: Nonthreatening experiences that are stimulating and interesting to the child have been observed to help raise IQ. Practices such as serving nutritious meals or letting the child play with more able children have not been supported by research as beneficial in increasing intelligence. Vasodilator medications act to increase oxygenation to the tissues, including the brain. However, these medications do not increase the child's IQ.

A nurse arriving for duty notes that an unlicensed assistive personnel (UAP) has been assigned to a complex client with treatments involving sterile technique. What is the responsibility of the nurse regarding the assignment of the UAP? Supervise the UAP during the treatments involving sterile technique. Make sure the UAP has practiced sterile technique on at least one other occasion. Provide the UAP with a list of resources to guide the implementation of care. Reassign the UAP to a client requiring basic tasks that the UAP has mastered.

Correct response: Reassign the UAP to a client requiring basic tasks that the UAP has mastered. Explanation: The nurse is accountable for the delegation of tasks to UAPs. The nurse delegates tasks to UAPs consistent with their level of expertise and education, the job description, agency policy, legislation, and personal need. UAPs should not be assigned to clients who are complex or require skills that involve a higher level of knowledge. Based on the choices offered, if the nurse is confident that the UAP has the appropriate knowledge regarding basic tasks, the tasks can be delegated. The other options are incorrect, as they do not ensure that the UAP has the knowledge and skill to provide the care or carry out the task.

A postmenopausal client is scheduled for a bone density scan. What should the nurse instruct the client to do? Report any significant pain to the health care provider at least 2 days before the test. Remove all metal objects on the day of the scan. Consume foods and beverages with a high content of calcium for 2 days before the test. Ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test.

Correct response: Remove all metal objects on the day of the scan. Explanation: Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis.

A nurse suspects that a coworker is taking and using narcotics from the medication cart. What would the nurse do first? Keep track of the quantity of medications in the cart throughout the shift. Discuss the suspicion directly with the coworker. Monitor the coworker's behaviors. Report the suspicion to the nurse manager.

Correct response: Report the suspicion to the nurse manager. Explanation: The nurse should report the suspicion to the nurse manager. The American Nurses Association does not advise confronting coworkers in these situations. Monitoring the coworker's behavior or keeping track of the quantity of medications in the cart do not solve these problem. These actions allow the coworker to continue working with clients while possibly under the influence of drugs, which is not safe.

A healthcare facility plans to evaluate and revise the plan of care for a client based on the client's medical records. The physician, dietitian, and nurse involved in the client's care are required to collate all information for easy access. Which style do you think the agency is following to record the client details? SOAP charting focus charting narrative charting PIE charting

Correct response: SOAP charting Explanation: In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. Narrative charting is time-consuming to write and read, as it involves sorting through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

The nursing student is having difficulty obtaining a mobile computer for the purpose of administering medications using the electronic medical record. The student has been reprimanded for delivering medications late in the past and wants to ensure timely administration. What action should the student take? Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one. Wait for a mobile computer to become available, and explain to the instructor that the reason for late administration was related to adhering to safety policy. Print a copy of the medication record at the nurse's station to use at the bedside in order to administer the medications on time. Use the medication dispensing terminal to prepare the medications, and print a dispensing receipt to use for patient identification at the beside.

Correct response: Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one. Explanation: When equipment is not readily available, it can be tempting to use work-arounds. Although down-time procedures may exist that allow for printing of the medication record, this is not the problem the student is facing. The student should make every effort to obtain the computer so the electronic medication record can be used appropriately for medication administration. Speaking to the instructor in advance, rather than afterwards, demonstrates superior communication and problem solving skills.

The nurse is providing care to several clients. In which situation would the nurse be able to accept a verbal order from the healthcare provider? The client reports new onset headache and has a blood pressure of 90/50 mm Hg. The client is hemorrhaging from a surgical wound. The client has just been admitted to the unit from the emergency department. The client is being transported to the cardiac catheterization department.

Correct response: The client is hemorrhaging from a surgical wound. Explanation: In most facilities, the only circumstance in which an attending healthcare provider may issue orders verbally is in a medical emergency, when the healthcare provider is present but finds it impossible to write the order. The postoperative hemorrhage is the only scenario that could be considered an emergency. Although the one client's blood pressure is low, there is no evidence there this is a potentially life-threatening situation. When clients are transferred between facilities or departments, there is time to write prescriptions, so the healthcare provider should enter these directly into the medical record as the safest form of documentation.

During the process of restraining a client, a staff member was injured. The nurse manager would decide that a peer support program has been helpful for the injured staff member if which outcome has been achieved? Select all that apply. Legal action has been taken against the client. The injured staff member has debriefed with other staff involved in the restraint. A plan has been arranged to facilitate the return of the injured staff member to work. The injured staff member has had the opportunity to express feelings with a support group. The injured staff member has decided whether to talk to the assaultive client.

Correct response: The injured staff member has debriefed with other staff involved in the restraint. The injured staff member has had the opportunity to express feelings with a support group. The injured staff member has decided whether to talk to the assaultive client. A plan has been arranged to facilitate the return of the injured staff member to work. Explanation: Talking with other staff and his personal support system help diminish fears and anger about being injured. It is appropriate to facilitate the injured staff member's return to work to decrease the chance of resignation or difficulties in performing duties. Talking with the assaultive client can be helpful if the client is apologetic but is not required. Legal action against a client is controversial and not always appropriate depending on the client's illness.

A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A person identifying themself as a family friend inquires if they can be of any help to the family. What should be the nurse's response be? The nurse should refer the person to the local social worker. The nurse should invite the person to learn the caring techniques. The nurse should state that the family does not need any help. The nurse should ask the person to talk to the family directly.

Correct response: The nurse should ask the person to talk to the family directly. Explanation: The nurse should ask the person to talk to the family directly. Revealing information about the client's care is a violation of the client's privacy. The nurse should not invite the person for a learning session because doing so would be a breach of the client's right to privacy. Referring the person to a social worker is not an appropriate choice.

An older adult client is being admitted to same-day surgery for cataract extraction. The client has several diamond rings. What information should the nurse give the client about how the rings will be secured during surgery? The rings will be locked in the narcotics box. The nursing supervisor will hold onto the rings until the client returns from the recovery room. The rings will be taped on the fingers before the surgery. The rings will be placed in an envelope, the client will sign the envelope, and the envelope will be placed in a safe.

Correct response: The rings will be placed in an envelope, the client will sign the envelope, and the envelope will be placed in a safe. Explanation: Under the policy for valuables, the nurse documents the description on an envelope with the client, the client and nurse sign the envelope, and the valuables envelope is locked in the safe. The other options increase the risk of loss or damage to the client's valuables.

An older adult alert and oriented client is admitted to the hospital for treatment of cellulitis of the left shoulder. Which fall prevention strategy is most appropriate for this client? Keep all the lights on in the room at all times. Use a night-light in the bathroom. Use a medical alert system. Keep all four side rails up at all times.

Correct response: Use a night-light in the bathroom. Explanation: Many falls occur when older clients attempt to get to the bathroom at night. The risk is even greater in an unfamiliar environment. Use of a nightlight in the bathroom enables the older adult client to see the way to the bathroom. Keeping the lights on in the room at all times may contribute to sensory overload and prevent adequate rest. Raised side rails paradoxically contribute to falls when the older client tries to climb over them to get to the bathroom. The upper side rails may be raised, but it is not recommended that all four side rails be elevated. Camera monitoring can be used but does nothing to prevent a fall.

A "read-back" procedure has been implemented on a nursing unit to prevent discrepancies in telephone prescriptions and reports. When should this procedure be implemented? When the float nurse gives a written report to the oncoming nurse When the lab report shows up on the computerized medical record When the nurse receives a critical lab value via phone or in-person from the lab When the unit clerk takes a telephone prescription for a stat lab test

Correct response: When the nurse receives a critical lab value via phone or in-person from the lab Explanation: For any verbal or telephone prescription or result, it is important to read back the information to assure its accuracy. It is also important to document that it was read back according to facility policy. It is not necessary to use "read-back" procedures when data are entered on the computerized medical record. The Unit clerk is not a licensed health care worker and should not take telephone prescriptions. When giving a written report, it is not necessary to "read back," but the nurse should always clarify if there is any question.

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 G1 P1 who is 1 day postpartum with an infant in the SCN a G1 P1 who is a non-English speaking client with infant in SCN for fetal distress a G4 P4 who is 2 days postpartum with infant, Spanish speaking only a G6 P6 who gave birth 4 hours ago by C/S for fetal distress, infant at bedside

Correct response: a G4 P4 who is 2 days postpartum with infant, Spanish speaking only Explanation: The ability to communicate with a person of the same language would be an advantage, an opportunity for socialization and support for the new mother who speaks Spanish. If a Spanish-speaking mother were placed with the client who also had a baby in SCN, she would have no communication opportunity, and the same would apply for rooming with the mother who has had a cesarean section. The client who is non-English speaking does not identify the language spoken, and the nurse cannot assume that it is Spanish.

The labor and birth nurse is assigned to triage for the day. There are four clients already in rooms, and 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 client with no prenatal care, occasional contractions, BP 148/90 mm Hg, and swollen feet a client who is at 42 weeks' gestation with bloody show, no contractions, rupture of membranes 1 hour ago leaking green fluid a primipara in active labor at 5 cm asking to be admitted and wanting an epidural a primipara who is 100% effaced, 8 cm dilated, + 2 station with nausea

Correct response: a client who is at 42 weeks' gestation with bloody show, no contractions, rupture of membranes 1 hour ago leaking green fluid Explanation: The client at 42 weeks' gestation is the greatest concern, and the nurse should make rounds on this client first based on the length of the pregnancy and the green color of the amniotic fluid. Bloody show is a normal sign of impending labor as the cervix may be beginning to dilate. Not having contractions after rupture of membranes is not unusual within a 1-hour time frame. The green amniotic fluid indicates that fetal distress has recently occurred to the point that the fetus had a bowel movement in utero. This occurrence, along with the 42-week gestation, places this fetus at greatest risk. The nurse can see the primipara in active labor at 5-cm dilation last; this client is in pain, but nothing about her situation indicates anything but a normal labor process, and as a primipara, her labor process will be slow. The client who is completely effaced, 8-cm dilated, and at +2 station is also a primipara, and thus will move through labor at a slower pace than a multiparous client. She is experiencing nausea that is an expected situation as a laboring client enters transition. The client with no prenatal care is a cause for concern because the nurse knows nothing about her background. Her blood pressure is elevated, an indicator of mild preeclampsia, but there are no other indications of worsening preeclampsia, such as headache, visual disturbances, or epigastric pain.

After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first? a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular a client with cirrhosis who is depressed and has refused to eat for the past 2 days 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 a client with pancreatitis whose family requests to speak with the HCP regarding the treatment plan

Correct response: a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular Explanation: A change in a client's baseline vital signs should be brought to the HCP's attention immediately. In this case, the client's heart rate has increased, and the rhythm appears to have changed; the HCP may prescribe an ECG to determine if treatment is necessary. The nurse should also have a complete set of current vital signs as well as a physical assessment before providing the HCP information using the SBAR format. The nutritional as well as psychological needs of a client must be addressed but are not first priority. A rash that develops after a new antibiotic is started must be brought to the HCP attention; however, this client is stable and is not the first priority. The nurse is responsible to facilitate discussion between the client, the client's family, and the HCP but only after all of the immediate physical and psychological needs of all clients have been met.

A client has been placed in an isolation room and family members have stated that access to the client seems restricted. Which actions would be appropriate for the nurse to take to address this situation? Select all that apply. acknowledgement of the family's concerns a communication plan for the family and client a thorough explanation of the isolation procedures discontinued isolation procedures at the family's request free access to the client for immediate family

Correct response: a communication plan for the family and client a thorough explanation of the isolation procedures acknowledgement of the family's concerns Explanation: To ensure that everyone complies with the isolation procedures, the nurse should develop a communication plan with the family and client, provide thorough explanations about the importance of complying with the isolation procedures, and address family and client concerns. Allowing free access or discontinuing isolation procedures at the family's request would be a safety violation.

What is a priority for the nurse developing a plan with a client admitted to the hospital with an acute exacerbation of rheumatoid arthritis? continuing to work on a positive self image because joint deformities are common in this disease achieving a controlled level of pain and fatigue throughout the day. accepting and working toward understanding long-term chronic illness always performing activities of daily living independently

Correct response: achieving a controlled level of pain and fatigue throughout the day. Explanation: Symptoms of rheumatoid arthritis include localized pain, stiffness, and decreased joint mobility after a period of rest, such as after sleeping. This can be more localized, which causes symptoms such as pain or stiffness. Lack of mobility over a period of time can increase the symptoms. Other answers are incorrect because they do not reflect management of care. Working on a positive self image is about self esteem. Always performing activities of daily living does not reflect promoting management; clients do not need to be independent. Accepting and working toward understanding is not about management.

When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be ambulating the client in the hallway. administering pain medication. allowing family members to visit a newly admitted client. placing wrist restraints on the client.

Correct response: administering pain medication. Explanation: In Maslow's hierarchy of needs, pain relief is on the first layer. Love and belonging, as in allowing family members to visit, are on the third layer. Activity, as in ambulation, is on the fifth layer. Safety, as in placing wrist restraints on the client, is on the second layer.

A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)? lack of adventitious lung sounds arterial oxygen level of 46 mm Hg (6.1 kPa) oxygen saturation of 96% on room air respirations of 12 breaths/min

Correct response: arterial oxygen level of 46 mm Hg (6.1 kPa) Explanation: Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg (6.1 kPa) to the HCP. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation.

A hospitalized client fell on the floor and sustained a small laceration on the hand that requires stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine with epinephrine and a suture kit in order to suture the laceration. Which issue should be resolved before proceeding with suturing? the cosmetic effect from not having a plastic surgeon do the suturing. the intern's ability to suture. bupivacaine with epinephrine used as the local anesthetic. the client's room as an aseptic environment.

Correct response: bupivacaine with epinephrine used as the local anesthetic. Explanation: The nurse should question the use of a local anesthetic agent with epinephrine on the hands or feet because the epinephrine is a vasoconstrictor and can cause ischemia and gangrene of extremities. The nurse should suggest that the intern use bupivacaine without epinephrine as the local anesthetic agent. An intern should be trained in suturing small superficial incisions, and the cosmetic effect should be acceptable. The client's room should be a sufficiently aseptic environment because there is no other client in the room.

What would be important environmental assessments for the home care nurse to explore with a client who is being discharged home? checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment ordering a wheelchair, special utensils, and a raised toilet seat and rearranging the furniture in the home checking the cleanliness of the home, ensuring removal of clutter, and organizing all essentials on one level of the house reinforcing the importance of having renovations done before discharge to enable wheelchair access and accessibility to all needs for daily living

Correct response: checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment Explanation: Safety and access in the client's home are important to assess before discharge to ensure that the client can manage at home.

A child with spastic cerebral palsy is to begin botulinum toxin type A injections. Which treatment goals should the health care team set for the child related to botulinum toxin? Select all that apply. improved nutritional status decreased pain from spasticity reduced caregiver strain decreased speech impediments enhanced self-esteem improved motor function

Correct response: decreased pain from spasticity improved motor function enhanced self-esteem reduced caregiver strain Explanation: Botulinum toxin injections can be used to improve many aspects of quality of life for the child with cerebral palsy. The injections can help decrease pain from spasticity. Injections improve motor status by reducing rigidity and allowing for more effective physical therapy to improve range of motion. Decreased spasms enhance self-esteem. Improved motor status facilitates the ability to provide some aspects of care, especially transfers. Botulinum does not significantly affect nutritional status or speech.

A healthcare agency has set a plan to apply for accreditation. A nurse on the accreditation committee has been assigned to audit clients' medical records for appropriate documentation. What information would the nurse assess in the audit? evidence of home care and nursing follow-up for 6 weeks following discharge evidence that nurses have set goals for improving future practice evidence that nursing interventions have been evaluated in terms of the client's response evidence of self-reflection from nursing and other care providers about the quality of their care

Correct response: evidence that nursing interventions have been evaluated in terms of the client's response Explanation: The medical record serves multiple purposes, including a role in accreditation. Accreditors look for evidence of evaluation following interventions. The medical record is not the correct venue for nurses' self-reflection or personal goal-setting. Many clients do not require community-based follow-up after they have been discharged.

A healthcare agency has set a plan to apply for accreditation. A nurse on the accreditation committee has been assigned to audit clients' medical records for appropriate documentation. What information would the nurse assess in the audit? evidence that nursing interventions have been evaluated in terms of the client's response evidence of self-reflection from nursing and other care providers about the quality of their care evidence of home care and nursing follow-up for 6 weeks following discharge evidence that nurses have set goals for improving future practice

A nurse on a night shift entered an elderly client's room during a scheduled check and discovered the client on the floor beside the 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? protecting the nurse and the hospital from litigation identifying risks and ensuring future safety for clients gauging the nurse's professional performance over time following up on the incident with other members of the care team

Correct response: identifying risks and ensuring future safety for clients Explanation: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action and they are not commonly used to communicate within the interdisciplinary team.

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal? charting by exception narrative notes SOAP notes focus charting

Correct response: narrative notes Explanation: One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. The charge nurse should: assess the nurse's behavior for signs of intoxication. report this to the nursing supervisor immediately. report this to the head nurse in the morning. ask the nurse if she has been drinking.

Correct response: report this to the nursing supervisor immediately. Explanation: This situation should be reported immediately to the nursing supervisor or manager at the time. The nurse is liable to report a suspicious situation that could create an unsafe situation for the clients. Reporting a suspicious situation does not imply actual guilt; it implies identification of a high-risk situation. The supervisor will then follow the correct procedure for management and follow-up of the situation. This situation requires immediate attention and cannot be delayed until the head nurse is available on the day shift. The charge nurse, or another staff nurse, should not confront the nurse; this is the responsibility of the nursing supervisor. Assessment of the nurse's behavior is not the nurse's responsibility; reporting the potentially unsafe situation is.

A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as moral values are considered to be universal the laws that govern acceptable and unacceptable behavior the principles that determine whether an act is right or wrong the relationship between law and culture

Correct response: the principles that determine whether an act is right or wrong Explanation: Ethics involves moral or philosophical principles that direct actions as being either right or wrong. Laws are often rooted in ethics but the two terms are not synonymous. Similarly, morals and values are closely associated with ethics but these do not constitute the definition of ethics. Ethics are not universally agreed upon, as many different applications exist.

The client had an ostomy created 3 days prior. The nurse is planning to teach the client how to empty the ostomy pouch. What is the best time for the nurse to conduct the teaching? the time that the nurse and client mutually agree upon before the client's lunch at the time the nurse perceives he or she will have time to conduct the teaching just prior to the end of the nurse's shift

Correct response: the time that the nurse and client mutually agree upon Explanation: The time to conduct the teaching should be mutually agreed upon by the nurse and client in order for the teaching to be most effective. Performing the teaching just prior to the end of the nurse's shift does not take into account when the client would feel most comfortable with the teaching. While it is important that the nurse has the time to conduct the teaching, it is also important that the client feels it is a good time for the teaching to occur. Conducting the teaching right before lunch does not take into account the client's feelings on when is a good time for the teaching to occur. Additionally, if the client is hungry, attention to the teaching might be hindered. Teaching is most effective when it occurs during a mutually agreed upon time.

The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply. to make data entry into a computerized health record easier to ensure efficient and accurate communication to ensure client safety to make it easier for clients to understand the medication prescription to prevent medication errors

Correct response: to ensure efficient and accurate communication to prevent medication errors to ensure client safety Explanation: Abbreviations can be misinterpreted and all health care professionals should avoid the use of easily misunderstood abbreviations. The purpose of avoiding abbreviations is not to make it easier for clients to understand the medication prescriptions or to make data entry easier.

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

Correct response: to make sure that prescriptions and test results that are communicated verbally or by telephone are clear to the receiver of the information to make sure that prescriptions and test results that are communicated verbally or by telephone are confirmed by the individual giving the information Explanation: A National Patient Safety Goal of The Joint Commission is to improve the effectiveness of communication among caregivers. The requirement for verbal or telephone prescriptions, or for telephonic reporting of critical test results, is to verify the complete prescription or test result by having the person receiving the information record and "read-back" the complete prescription or test result. Effective communication which is timely, accurate, complete, unambiguous, and understood by the recipient reduces error and results in improved client safety. "Read-back" procedures are not intended to discourage or prohibit telephone communications among health care providers (HCPs) or to promote use of electronic medical records. Safety procedures, such as provider identification codes, are in place for HCPs to give verbal or telephone prescriptions.

Which of the following items of subjective client data would be documented in the medical record by the nurse? A. Client's face is pale B. Cervical lymph nodes are palpable C. Nursing assistant reports client refused lunch D. Client feel nauseated

D. Client feel nauseated Rationale: Subjective data includes the client's sensations, feelings, and perception of health status. Subjective data can only be verified by the affected person. Options 1, 2, and 3 represent objective data that can be detected by the nurse or measured against an accepted norm.

A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, "I'm tired of being sick. I wish I could end it all." What is the most accurate and informative way to record this data in a nursing progress note? A. Client appears to be depressed, possibly suicidal B. Client reports being tired of being ill and wants to die C. Client does not want to live any longer and is tired of being ill D. Client states, "I'm tired of being sick. I wish I could end it all."

D. Client states, "I'm tired of being sick. I wish I could end it all." Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

In giving a change-of-shift report, which type of client information communicated by the nurse is most appropriate? A. Vital signs are stable B. Client is pleasant, alert, and oriented to time, place, and person C. The chest x-ray results were negative D. Client voided 250 mL of urine 2 hours after the urinary catheter removal

D. Client voided 250 mL of urine 2 hours after the urinary catheter removal Rationale: A change-of-shift report should include significant changes (good or bad) in a client's condition. The information should be accurate, concise, clear, and complete. Options 1 is vague and options 2 and 3 are normal data and are therefore of lesser importance to convey in the change-of-shift report.

The nurse would write which of the following outcome statements for a client starting an exercise program? A. Client will walk quickly three times a day B. Client will be able to walk a mile C. Client will have no alteration in breathing during the walk D. Client will progress to walking a 20-minute mile in one month

D. Client will progress to walking a 20-minute mile in one month Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. They should also be realistic and achievable.

The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team? A. Use Liquid PaperTM to "white out" the resolve diagnosis on the care plan B. Recopy the care plan without the resolve diagnosis C. Write a nursing process not indicating that the outcome goals have been achieved D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date

D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a "Date Resolved" column. Using Liquid PaperTM is not a legal way to amend client records. Outcome goals that have been met and nursing diagnoses that have been resolved should be documented on the care plan. A progress note should also be written, but a single note may not be read by all health team members.

Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A. Diagnosis B. Planning C. Implementation D. Evaluation

D. Evaluation Rationale: Evaluating is the process of comparing client responses to the outcome goals to determine whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks, and strengths. Planning is the formulation of client goals and nursing strategies (interventions) required to prevent, reduce, or eliminate the client's health problems. Implementing is carrying out or delegating the nursing interventions.

For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse? A. Discomfort B. Deficit C. Feeding D. Fractured wrists

D. Fractured Wrists Rationale: The etiology or related factors of a nursing diagnostic statement define one or more probable causes of the problem and allow the nurse to individualize the client's care. In this case, the fracture is the cause of the client's feeding problem.

The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care? A. Nursing diagnosis/problem list B. Nursing orders C. Short-term goals D. Long-term goals

D. Long-term goals Rationale: Long-term goals describe changes in client behavior expected over a time frame greater than one week. They are usually designed to restore normal functioning in a problem area and are helpful to other healthcare workers who care for the client, often in a variety of settings.

A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition

D. Nurse rapidly reset priorities for client care based on a change in the client's condition Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process.

While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? A. Help client into the chair but more quickly B. Document client's vital signs taken just prior to moving the client C. Help client back to bed immediately D. Observe client's skin color and take another set of vital signs

D. Observe client's skin color and take another set of vital signs Rationale: Assessment is ongoing throughout the nurse-client relationship. During re-assessment, the nurse collects additional data to help evaluate the status of problems or identify new problems. Options 1, 2, and 3 are interventions.

The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior B. Conditions or modifiers C. Performance criteria D. Target time

D. Target time Rationale: The outcome goal does not state the target timeframe for when the nurse should expect to see the client behavior ("transfer"). The condition or modifier is present ("with two assists"). The performance criterion is "from bed to chair."

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