chpt 10

The nurse is caring for an underweight client diagnosed with a new food allergy to wheat, rye, and oats. What is the most appropriate intervention for this client with a nursing diagnosis of imbalanced nutrition: less than body requirements?

Administer 2500 calorie diet, excluding wheat, rye, and oats

The nurse is performing an assessment on a client who presents with a rash. The client states that the rash is on his back and is red and raised. What would be the most appropriate nursing action?

Assess the client's back visually.

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

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

An older adult client presents to the clinic with abdominal pain and loss of appetite. The nurse's assessment reveals a distended abdomen and the client reports that he has not had a stool in 4 days. The client is on multiple medications that have various side effects. Which nursing diagnosis is an actual health problem for this client at this time?

Constipation

Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this followup with the client, the nurse is utilizing which step of the nursing process?

Evaluation

Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?

Evaluation

The nurse understands that research has demonstrated that a common source of hospital-acquired infections in clients with IV infusions is the hub on the IV tubing. Which Quality and Safety Education for Nurses (QSEN) competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing?

Evidence-based practice

A hospitalized client is being treated for sepsis. The client's vital signs are stable and she is afebrile. She is anxious about going home and still feels very weak and states that she is too weak to go back to work. Which nursing diagnosis has been resolved and should be deleted from this client's plan of care?

Ineffective thermoregulation

Two nurses have disagreed about the role of intuition in nursing practice, with one nurse characterizing it as "hocus-pocus" and the other nurse advocating it as a superior problem-solving strategy. Which of the following statements best conveys the role of intuition in nurses' problem solving?

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

Which of the following is a true statement regarding critical thinking in nursing?

It is a systemic way of thinking

The nurse enters the room of an adult client who complains of postoperative abdominal pain. The client states that the pain is severe, but is relieved some when she gets up to go the bathroom. What is the nurse's best determination based on this assessment?

More assessment would be beneficial to determine if pain medication is desirable.

The nurse recognizes that the most appropriate example of the assessment phase of the nursing process is which of the following?

Palpating a mass in the right lower quadrant of the abdomen

The nurse has measured from the tip of the client's nose to his earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which of the following components of the nursing process has the nurse demonstrated?

Planning; implementing

The student nurse has been assigned to a pediatric hospital floor next week. The student understands that he or she is expected to be able to use the syringe pump with the clinical instructor when giving medications. The student has never used this pump before and is anxious. What is the most appropriate way for the student to lessen the anxiety associated with the clinical rotation?

Practice using the pump in the lab setting if it is available and with instructor permission.

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

Prioritize the nursing diagnoses.

Which of the following statements does the student nurse recognize that is true about the benefits of using the Nursing Process?

Promotes clear, efficient, and cost-effective care to provided to all clients

What is meant by intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new meanings and appreciations?

Reflection

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

Respect for the client, and engaging in open communication in getting to know the client.

Which of the following statements is true of the nursing process?

Scientific problem solving can occur within the nursing process.

The nurse is caring for a morbidly obese client with a very high body mass index (BMI). After analyzing the assessment data, a nursing diagnosis of Altered Nutrition: More than Body Requirements is included in the client's plan of care. What is the best example of outcome identification and planning for this client using the nursing process?

The client is involved in developing a comprehensive and individualized plan of care with specific outcomes.

The nurse uses the QSEN competency of Informatics when planning care for patients. What is an example of the use of this skill?

The nurse researches new technological advances in the treatment of cancer.

Use of the nursing process in healthcare allows the nurse to address the needs of the client. The nursing process:

provides a universally applicable framework for nursing activities.

The nursing student recognizes that the most appropriate intervention for a newly diagnosed diabetic client with a nursing diagnosis of deficient knowledge is to:

teach the client how to administer his own insulin.

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

uses critical thinking to direct care for the individual patent.

Nurses use the nursing process to plan care for patients. In which case is the nursing process applicable? (Select all that apply.)

• When nurses work with patients who are able to participate in their care • When families are clearly supportive and wish to participate in care • When patients are totally dependent on the nurse for care • When families are not supportive and do not wish to participate in care

Then nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process?

Assessment

The nurse is caring for a client who has been in the hospital for 7 days. When the nurse enters the room to perform the morning assessment, the client tells the nurse he can't wait to go home. What statement by the nurse demonstrates that the nurse is skilled in developing caring relationships?

"What do you miss most about being away from home?"

The nurse is caring for a client that presents with polydipsia, polyphagia, and polyuria. The clients labs reveal in increased Hgb A1C, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?

Analyze data and create an individualized nursing diagnosis.

The nurse is caring for an obese client that needs to be turned every 2 hours. Which nursing action is an example of reflection for action?

During her first attempt to turn the client, she realizes that she really needs assistance and calls the front desk for help. After her shift is over, she wonders if all health care providers are using the appropriate resources when turning this client. The next day, the nurse institutes, as part of the client's plan of care, assistance with turning so that the client gets optimal care without injury to the caregivers.

A client is admitted to the hospital with an abscess on his leg that will not heal after multiple treatment options as an outpatient. The nurse knows from past experiences that the appearance of this type of wound in clients heavily suggests a resistant bacterial infection and the need for contact isolation and IV antibiotics, so she begins to prepare for this admission. What type of problem solving does this exhibit?

Intuitive

Your patient has had major abdominal surgery and just returned to the unit from the operating room. Your nursing priority is to:

complete post-operative assessment.