Foundations Test #5 part 2
A client is scheduled for a CABG procedure. What information should the nurse provide to the client?
"A coronary artery bypass graft will benefit your heart."
A staff nurse comments to the charge nurse that it is unnecessary to know how to formulate nursing diagnoses because the computerized documentation system generates them automatically. What is the most appropriate response by the charge nurse?
"A nurse is still responsible for using critical thinking to determine the validity of the nursing diagnoses generated."
A nurse is transfusing multiple units of packed red blood cells. After the second unit is transfused, the nurse auscultates bilateral crackles at the bases of the client's lungs and the client reports dyspnea. The nurse telephones the health care provider and provides an SBAR report. Which statement represents the final step in this type of communication?
"I think the client would benefit from intravenous furosemide."
A nurse asks a nurse manager why staff nurses on the unit cannot document in a separate record (instead of the client record) to make it easier to find information on nursing-specific actions. What is the best response by the nurse?
"Legal policy requires nursing practice to be permanently integrated into the client record."
Which statement by the nurse is the best example of an internal communication strategy the nurse should use to discuss the use of new equipment, client care problems, and change in policies?
"We will be having a team conference to discuss concerns that clients' relatives have raised."
The nurse calls the health care provider due to changes in the client's status. Using the SBAR, the nurse is about to address Recommendation. Which statement appropriately supports the part of the SBAR?
"Will you prescribe a complete blood count to check the white blood cell count and a culture?"
A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of the information?
1 Unit of glucose
The nurse is caring for a client admitted with acute pancreatitis. The client is nauseated and receiving IV fluids at 125 mL/hr. The client is NPO and has received morphine sulfate 4 mg IV for pain with a decrease of epigastric pain of a 4/10 on the pain scale. Because the facility charts by exception, which progress note represents this method?
4/10 pain on pain scale, epigastric pain; with reports of nausea.
A nurse is arranging for home care for clients and reviews the Medicare reimbursement requirements. Which client meets one of these requirements?
A client who is homebound and needs skilled nursing care
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
Which statement is true regarding addressing a priority problem?
A priority problem requires a nursing intervention before another problem is addressed.
A nurse is using Gordon's functional health patterns as an organizing framework for client assessment. The client has significant problems related to breathing, for which the nurse identifies several nursing diagnostic labels, including ineffective breathing pattern and impaired gas exchange. The nurse understands that these nursing diagnoses would be organized under which functional pattern?
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
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
The parent of a 33 year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. What action by the nurse is most appropriate?
Ask the client if information can be given to the parent.
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 case of the pain
Which guidelines should the nurse consider when writing outcomes?
At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis The nurse should write outcomes that are brief and specific and support the overall plan of care
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 group of terms best defines assessing in the nursing process?
Collection, validation, communication of client data
What are nursing diagnoses based on?
Cues
A client has been discharged from an acute care facility with a referral for a home health nurse to make an assessment. What is the priority action by the home health nurse on the initial home visit?
Establish the client's database
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
Which are high-risk errors in documentation?
Inadequate admission assessment Failure to document completely Charting in advance Falsifying client records
A client is being admitted from the ER reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?
Ineffective airway clearance
The nurse is preparing a client with a bowel obstruction for emergency surgery. Which intervention has the highest priority for this client?
Inform the client what to expect after the 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
What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?
NANDA-International (NANDA-I)
A 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, three times per day, leads to expedited discharge. What type of evaluation best described what the researches are examining?
Outcome
The nurse hears an unlicensed assistive personnel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action?
Remind the UAP about the client's right to privacy.
An older adult client's venous ulcer has become foul-smelling after the client began using strips of a sheet to dress the wound due to running out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this client's circumstances?
Risk for Infection related to knowledge deficit.
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
What is an advantage of using the functional health patterns model for assessment?
The nurse can identify client strengths and assets
Which finding from a nursing audit reflects high standards for client safety and institutional health care?
The nurse documents clients' responses to nursing interventions.
The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which information?
The physician's assessment and treatment
What is the purpose of establishing a nursing diagnosis?
To describe a functional health problem
The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next?
Validate the data
What is an example of a psychomotor outcome?
Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.
Can a nurse develop a nursing diagnosis when there is not enough evidence to support the presence of a problem, but the nurse would like to gather more evidence?
Yes, this defines a possible nursing diagnosis
The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is:
a clinical pathway
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
A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has:
a lack of cues, or premature closure
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:
have the right to copy their health records
The primary purpose of nursing implementation is to:
help the client achieve optimal levels of health
When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of:
interpretation of data
A treatment based on a nurse's clinical judgement and knowledge to enhance client outcomes is a nursing:
intervention
What are specific measurable and realistic statements of goal attainment?
outcomes
A nurse makes a nursing diagnosis of Constipation after a client reports not defecating on the last trip to the bathroom. The nurse has no other information on the client's defecation history. This is an example of:
premature closure
The nurse is interviewing a newly admitted client. Quoting statement made by the client will help in maintaining what type of assessment data?
subjectivity
Which type of assessment would the nurse be expected to perform on the client who is 1 day postoperative following a cholecystectomy?
Focused
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
The home health nurse is performing an assessment related to the client's ability to manage activities of daily living in the home environment. Which assessment is the nurse performing?
Functional assessment
Which statement is not true regarding a medication administration record (MAR).
If the client declines the dose, the nurse does not have to document this on the MAR.
The parents of a hospitalized 10-year old ask the nurse if they can review the health care records of their child. What is the appropriate response from the nurse?
"I will arrange access for you to review the record after you put you request in writing."
The nurse is caring for a client who requests to see one's medical record since admission to the hospital. What is the appropriate response by the nurse?
"I will have to review the policy that determines what procedure is in place for client access."
An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate?
"It combines nursing science with information management and analytical sciences."
A nurse is requesting to receive the change-of-shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving it at the bedside. Which response by the nurse receiving the report is most appropriate?
"It will allow for us to see the client and possibly increase client participation in care."
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 nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as?
A variance
"Acute Pain related to instillation of peritoneal dialysate as evidenced by client wincing and grimacing during procedure, client description of experience as 'stabbing'" is an example of which type of nursing diagnosis?
Actual nursing diagnosis
Which is the purpose of a focused assessment?
Adds depth to existing information
Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?
Altered Gas Exchange
Which guidelines should the nurse consider when writing outcomes?
At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis The nurse should write outcomes that are brief and specific and support the overall plan of care.
Which guideline should the nurse follow when including interventions in a plan of care?
Date the nursing interventions when written and when the plan of care is reviewed
The nurse is assessing a client who was admitted to the unit following an abdominal hysterectomy. On which assessment finding would the nurse base the priority diagnosis?
Diminished breath sounds in left lower lobe
Which are appropriate actions for protecting clients' identities? Select all that apply.
Document all personnel who have accessed a client's record. Place light boxes for examining X-rays with the client's name in private areas. Have conversations about clients in private places where they cannot be overheard
A 24 year old client present to the ED with signs and symptoms of a sickle cell crisis. The nurse quickly obtains the necessary laboratory tests to assist with the assessment, as well as conducts an assessment of the client to determine the proper nursing care the client will require. Which type of assessment did the nurse perform in this situation?
Emergency
After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data?
Hierarchy of Human Needs
When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:
Identifies factors causing undesirable response and preventing desired change
When developing a nursing diagnosis for a client, which should the nurse do first?
Identify the significant data
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?
Nurse case manager
The formulation of nursing diagnoses is unique to the nursing profession. Which statement accurately represents a characteristic of diagnosing?
Nurses write nursing diagnoses to describe client problems that nurses can treat
A computerized information system developed to classify client outcomes is the:
Nursing Outcome Classification System
Which elements are common to any type of plan of care?
Nursing diagnoses Client goals Nursing interventions
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.
Which principle should guide the nurse's documentation of entries on the client's health care record?
Precise measurements should be used rather than approximations.
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
What dual purpose does an audit serve?
Quality assurance and reimbursement
The nurse is using the SBAR technique for hand-off communication when transferring a client. Which scenarios are examples of using of this process?
S: the nurse handling the transfer describes the client situation to the new nurse B: the nurse gives the background of the client by explaining the client history A: the nurse presents an assessment of the client of the new nurse R: the nurse gives recommendations for future care to the new nurse in charge
A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client?
Updating the diet orders in the client's plan of care
The nurse is caring for a client whose spouse wishes to see the electronic health record. What is the appropriate nursing response?
"Only authorized persons are allowed to access client records."
The nurse is using the ISBARR format to report a surgical client's deteriorating condition to a health care provider. Which actions would the nurse perform when using this guide? Select all that apply.
After introductions, the nurse states the client name, room number, and problem. The nurse states that the client's condition "could be life-threatening." The nurse reads back the physician's new orders at the conclusion of the call.
A nurse is taking care of a 15 year old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation?
Attach a copy of the incident report to the chart
The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records?
Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers.
The nurse is caring for a client who is experiencing hypotension. The nurse is concerned about the significant drop in the client's blood pressure and decides to contact the client's health care provider. When preparing a report for the health care provider using the SBAR format, what will the nurse include?
The client's blood pressure trend over the past 24 hrs The primary reason the client was admitted to the hospital Objective and subjective data from the most recent assessment An explanation of what is needed to improve the hypotensive state.
When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:
the interventions planned must be within the nurse's scope of practice
When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:
the interventions planned must be within the nurse's scope of practice.
The nurse is aware that nursing diagnoses are:
within the nursing scope of practice to develop and client-focused.