Exam 2 PrepU

Which is an independent (nurse-initiated) action?

Helping to allay a client's fears about surgery

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?

Knowledge Deficit: Medications related to new medical diagnosis

A client has been diagnosed with a recent myocardial infarction. What collaborative problem would be the priority for the nurse to address?

PC: Decreased Cardiac Output related to cardiac tissue damage

A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed:

Peer review

The nursing supervisor is presenting the staff nurses with yearly performance evaluations. What type of evaluation is the supervisor presenting to the staff?

Process

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Psychomotor

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

Quality assurance

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder

Which is an example of a nurse-initiated intervention?

Teach the client how to splint an abdominal incision when coughing and deep breathing

A client with a new diagnosis of diabetes will be discharged on insulin therapy. Which client psychomotor outcome does the nurse expect after client education?

The client demonstrates administration of insulin.

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

The client is able to explain when and why the client needs to check the blood glucose level

Which outcome for a client with a new colostomy is written correctly?

The client will demonstrate proper care of the stoma by 3/29/20.

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision?

The client will understand the effects of smoking related to heart disease.

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

Which characteristic is the most important indicator of high-quality nursing practice?

The nurse considers the individual needs of clients.

The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up?

The nurse encourages the client to participate in all treatment decisions as the center of the health care team.

Which action by the nurse is an example of peer review?

The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD). Which statement would the nurse use to teach the client about effective breathing patterns?

"Leaning forward may help you to breathe better."

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status?

"My wife's been gone for about 7 months now."

Which action should the nurse take during the evaluation phase of the nursing process?

Document reassessment of pain after medication administration

The expected outcome for a client with a new diagnosis of rheumatoid arthritis (RA) is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I should call my health care provider if I have a sore that won't heal."

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

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

Which are activities the nurse typically performs during the implementation step of the nursing process? Select all that apply.

- Collecting additional client data - Modifying the client plan of care

Which are components of an evaluative statement? Select all that apply.

- Description of how the client outcome was met - Client data that support how the outcome was met

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply.

- The client's respiratory rate decreases. - The client states, "I can breathe easier now." - The client's oxygen saturation level increases.

A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain?

Implement the ABC guide of pain management.

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?

Ongoing

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse

A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement?

Physical changes

The nurse manager observes one of the unit nurses failing to wash hands on entering a client room. Hospital protocol is to wash hands before and after entering a client room. This scenario is an example of which approach to quality assurance?

Quality by inspection

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

Reassess the appropriateness of the method of instruction.

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in?

Supportive

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

Surveillance

A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client?

The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath.

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply.

- The client verbalizes understanding of the instructions. - The client is able to answer the nurse's questions. - The client discusses the specifics of what was taught during the session.

The nurse is caring for a client who is postoperative day 2 after a total knee replacement. The client refuses to ambulate when the physiotherapist arrives at the unit. The client states, "It is too soon to get up and walk. I am worried my incision will tear open." The nurse correctly documents the problem-focused nursing diagnosis using which statement?

Impaired physical mobility related to anxiety as evidenced by expressed fear of postoperative complications.

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client?

Opioid analgesic to treat pain

Which action should the nurse perform during the planning step of the nursing process?

Selects nursing measures, including client education

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?

On the client's admission to the hospital

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care?

Reassess the client to determine the effectiveness of the interventions.

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention?

Surveillance

The nurse is preparing to evaluate the goals set for a newborn and mother. What physiologic goals will the nurse evaluate for effectiveness? Select all that apply.

- By 4/6/20, the newborn will demonstrate 2 hours of sleep prior to breastfeeding at night. - By 4/6/20, the mother will demonstrate a pain rating of 0 on a 0 to 10 scale. - Before discharge, the baby with a birth weight of 7 lb, 6 oz (3.3 kg) will have reached a target weight of 8 lb (3.6 kg).

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.

Which statements are true about informatics in nursing practice? Select all that apply.

Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. Utilization of information services helps to support decision making.

A nurse documents the following in the client chart: Risk for Decreased Cardiac Output related to myocardial ischemia. This is an example of what aspect of client care?

Nursing diagnosis

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

Objective

The nurse is assessing a client for changes in health condition. After listening to the client's lungs for adventitious breath sounds, the nurse also checks the client's latest white blood cell count. The nurse is gathering which type of data when looking up the lab value?

Objective

Which nursing skill uses all five senses?

Observation

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

Risk for Community Contamination related to possible environmental pollution

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client?

Risk for Impaired Parenting

Which statement appropriately identifies a risk nursing diagnosis for a client who is confined to bed?

Risk for Impaired Skin Integrity related to bed rest

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

The nurse should determine the reason for the client's refusal.

The nurse is caring for a hospitalized client. The nurse explains to the client that a care plan will be used for which reason(s)? Select all that apply.

- to improve the communication between nurses about the client's care needs - to revise the care provided when planned interventions are not effective - to ensure that the client is involved in decision making about care

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

Condition

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

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

Which is the purpose of a focused assessment?

Adds depth to existing information

A client reports not having a bowel movement for 7 days, followed by a day of small, loose stools. How does the nurse define the health problem?

Constipation related to irregular evacuation patterns

Which client situation most likely warrants a time-lapse nursing assessment?

An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client expresses being nervous and informs the nurse that this the first time that the client has been admitted to a health care facility for an illness. Which diagnostic label would the nurse use to formulate the nursing diagnosis?

Anxiety

When is the best time for a nurse to take a client's health history?

As soon as possible after a client presents for care

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

Assess the client to determine the cause of the pain.

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

Assess the client's response to the ambulation.

A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process?

Assessment

The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which should the nurse recognize as an example of outcome evaluation?

A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery

A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client?

A client with a high fever receiving intravenous fluids, antibiotics, and oxygen

A pregnant client asks the nurse for information on breastfeeding. What type of nursing diagnosis should the nurse formulate?

A health promotion nursing diagnosis

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family?

A plan designed to support the client physically

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action?

Coordinate with the other disciplines to schedule the tests with adequate rest for the client

The nurse is preparing to assess a new client just admitted to the unit. The nurse prepares to interview the client and complete an assessment. Place the following steps in the order in which the nurse will complete them. Use all options.

- Reviews the client's past medical history - Introduces oneself to the client - Asks pertinent questions - Establishes goals of care to best help client

Which are cognitive client outcomes? Select all that apply.

- The client lists the side effects of digoxin. - The client describes how to perform progressive muscle relaxation. - The client identifies signs and symptoms of hypoglycemia.

A client is caring for the client's mother-in-law, who is an older adult who requires assistance with performing activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain?

"I just don't have time to take a shower."

Which statement by a nurse case manager regarding this nurse's role in client care is most accurate?

"I provide indirect care to my clients by coordinating their treatment with other disciplines."

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

The nurse is providing education to a group of middle school students regarding cold weather safety. One of the students asks the nurse how cold her body will get when it is cold outside waiting for the school bus. The nurse responds:

"We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time."

The nurse auscultates the breath sounds of a toddler during an assessment and notes crackles over all lung fields. What would the nurse teach the parents about this finding?

"We need to validate the information obtained in this assessment."

An 80-year-old client presents to the clinic, reporting a headache that has continued for the past 4 days. Which question(s) should the nurse prioritize in the assessment? Select all that apply.

- "Have you experienced any falls and hit your head?" - "Are you having any dizziness?" - "Is the headache affecting your vision?"

The night shift nurse is caring for a hospitalized client who reports being unable to sleep. The client states, "I just can't sleep here. I miss my home. There are too many lights and it is too hot." Which would be the best nursing diagnosis for this client?

Disturbed sleep pattern

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?

Educational

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse?

Encourage hourly use of the incentive spirometer.

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention?

Encourage the client to provide as much self-care as possible.

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

Nurse case manager

While performing an assessment on a young client, the nurse is using the Functional Health Patterns Model. When recording the facts that the client exercises daily, hikes weekly, and plays on a softball team regularly, under which heading should these data be clustered ?

Activity/Exercise

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

Actual

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

Bowel Incontinence

Which is the best source of information for the nurse when collecting data for an assessment?

Client

Which parties are essential for the nurse to include in the implementation of a client's plan of care?

Client, family, and physician

A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy?

Close the door to the room, explain the procedure to the client, and cover all areas of the client, only exposing the area for catheterization.

The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool and pale with capillary refill > 3 seconds, diminished dorsalis pedis and posterior tibial pulses, client reports cramping pain in left foot. The nurse is doing what?

Clustering significant data cues

"The client will verbalize appropriate cast care on discharge" represents which type of outcome?

Cognitive

Which type of health problem requires both physician- and nurse-prescribed actions to address?

Collaborative health problem

Which statement related to the evaluation of outcome attainment for a client is correct?

Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria.

Which group of terms best defines assessing in the nursing process?

Collection, validation, communication of client data

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders.

The client, who is 8 weeks pregnant as the result of a rape, tells the nurse, "I do not want to have this baby, but I have always believed that abortion is a sin. I don't know what to do." What nursing diagnosis would be most appropriate for the nurse to formulate?

Decisional Conflict related to conflict with moral beliefs as evidenced by the client's statement

Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?

Descriptors

Which describes the best approach for the development of nursing diagnoses?

Develop nursing diagnoses from clusters of significant data

A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem?

Disturbed Body Image related to loss of hair

The nurse is preparing to conduct an assessment on a new client of Chinese descent who is being admitted for abdominal surgery. Which step should the nurse prioritize during the assessment with this client?

Explain the nurse will need to touch the client during the assessment

A client with a history of benign prostatic hyperplasia presents to the emergency room with reports of urinary retention. The nurse collects data related to the client's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing?

Focused

A nurse documents the following nursing diagnosis on a client's plan of care: "Fluid Volume Deficit related to gastrointestinal upset from food poisoning as evidenced by vomiting and diarrhea for the past three days, slow skin turgor, and weight loss." The nurse identifies which part of the statement as the etiology?

Gastrointestinal upset from food poisoning

What must the nurse do to identify actual or potential health problems?

Gather data from sources

A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis?

Health promotion

The nurse is caring for an adolescent verbalizing a desire to seek counseling for grief related to the death of a close friend. The nurse determines that an appropriate nursing diagnosis for this client is Readiness for Enhanced Coping. What type of nursing diagnosis is Readiness for Enhanced Coping?

Health promotion nursing diagnosis

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client?

High Risk for Injury related to unsafe home environment

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem?

Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis

When developing nursing diagnoses, the nurse should focus on which area?

Human responses to actual or potential health problems

A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply.

Impaired mobility Imbalanced nutrition Ineffective coping

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?

Ineffective Airway Clearance

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?

Ineffective Health Maintenance related to client's denial of illness

The nurse is assessing a 3-week-old infant who has not gained weight since birth. The infant's bowel sounds are present in all quadrants and breath sounds are clear to auscultation. The infant's mother reports that the child cries much of the night but sleeps better in the daytime. The mother reports that the child only breastfeeds about four times in a 24-hour period and that the mother doesn't seem to have much milk. Which nursing diagnosis would be of highest priority for this client?

Ineffective breastfeeding

Which are examples of subjective data? Select all that apply.

Nausea Anxiety Light-headedness

The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next?

Notify the physician of the change and document the finding.

What are specific measurable and realistic statements of goal attainment?

Outcomes

When assessing the firmness of a client's abdomen, the nurse should use which assessment technique?

Palpation

Which is a legal responsibility of a nurse who has documented a nursing diagnosis related to a client's kidney failure?

Reporting signs and symptoms related to the client's kidney failure

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan?

Risk for Allergy Response related to latex allergy

A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? Select all that apply.

Stating "My legs feel like they are burning" Redness and blisters forming on both legs Crying and trying to scratch legs due to itching

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg?

Subjective

Which is the primary reason for a nurse collecting data continuously on a client?

The client's health status can change quickly.

Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training?

The nurse introduces oneself to the client by pointing to the nurse's name badge.

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse's most appropriate course of action?

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

An experienced nurse is orienting a new nurse to the unit. Which activity demonstrates the nurse is an effective caregiver?

The nurse uses open-ended questions when working with a crying client.

A client is admitted to a hospital unit with scleroderma. The nurse is unfamiliar with this condition. What is the nurse's best source of information about this condition?

The nursing and medical literature

Why are quality-assurance programs important in nursing?

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

A nurse practitioner in private practice with a physician is providing psychiatric care to a client with a history of being abused by a spouse. During the last visit, the client stated an intent to leave the spouse. In the next visit, the nurse practitioner will reassess the client's commitment to this intended change. What type of assessment is the nurse practitioner implementing?

Time-lapse

The nurse is comparing a client's current status to baseline data obtained upon admission to long-term care facility 6 months previously. Which tool should the nurse use to make this form of assessment?

Time-lapsed assessment

When performing an assessment, the nurse should focus most on the developmental stage for which client?

Toddler

While doing an assessment, the nurse identifies questionable data. Which should the nurse do first?

Validate the questionable data.

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent?

Verb (action)

A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action?

Verbally report the finding immediately to the client's physician.

The nurse has established client outcomes and outcome criteria. What should the nurse do next?

Write a client plan of care

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:

a cognitive outcome.

The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side." This statement is an example of:

a cue

The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called:

actual or potential nursing diagnoses.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning.

A nurse, who is caring for a client admitted to the patient care unit with acute abdominal pain, formulates the care plan for the client. Which nursing diagnosis is the priority for this client?

impaired comfort

The nurse is caring for a client with right-sided weakness after having a cerebrovascular accident (CVA). While conducting the head-to-toe assessment, the nurse notices the client has redness around the right elbow. When developing the client's care plan, which problem-focused nursing diagnosis will the nurse include?

impaired skin integrity of right elbow related to immobility due to right-sided weakness

During the introductory phase of interviewing a client for the purpose of obtaining information for the nursing history, the nurse should:

inform the client of the maintenance of confidentiality.

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.

Self-evaluation is a method that nurses use to promote their own development and to grow in confidence in their nursing roles. This process is referred to as:

reflective practice

The nursing instructor is teaching students about assessment and the importance of having baseline data when caring for clients. The instructor should inform the students that the best place to get baseline data is:

the initial comprehensive client assessment.

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse:

uses broad, open statements to communicate with the client.

A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client?

Asking whether the client feels less anxious 30 minutes after administering the medicine

A large university hospital has commissioned a multidisciplinary group to review client records following discharge to evaluate client outcomes and the character and quality of nursing care that clients receive. Which type of evaluation process will take place?

A nursing audit

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

Add the nursing diagnosis: Risk for Self-Harm.

A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?

Another registered nurse with critical care certification

A nurse suspects that the client with Crohn's disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse's most appropriate action?

Ask the client to verbalize the medication regimen and diet modifications required.

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action?

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

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

Communicate with the physicians to coordinate their orders.

Which are appropriate guidelines for the nurse to follow when delegating tasks to an unlicensed assistive personnel (UAP)? Select all that apply.

Delegate tasks that are within the UAP's scope of practice. Delegate tasks that involve minimal risk. Provide appropriate supervision when delegating tasks. Provide feedback to the UAP after the task is completed.

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

Developing the plan without client input

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

Discontinue the education and attempt at another time.

The nurse on a busy acute care floor identifies that several clients with heart failure are being readmitted within 2 weeks of discharge. Which step in performance improvement is the nurse demonstrating?

Discovering a problem

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond?

Discuss with the client the reasons for declining surgery.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?

Go to the client and assess the client's pain.

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

Nursing assistant

Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement?

Psychomotor

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

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

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?

Standardized

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?

Start from client's knowledge, teach about diet modifications, and check for learning.

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client with continuous pulse oximetry who requires pharyngeal suctioning.

Which nursing action reflects evaluation?

The nurse assesses the client's response to pain medication.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame.

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

outcome

The focus of a hospital's current quality assurance program is a comparison of the health status of clients on admission and with that at the time of discharge. This form of quality assurance is characteristic of:

outcome evaluation

"The levels of performance accepted by and expected of nursing staff or other health team members" defines:

standards

One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated?

throughout the client's hospital admission