Fundamentals- Ch.13

A nurse is working with a group of staff members to address the needs of a client as they develop the client's interdisciplinary plan of care. Which question if asked by the nurse addresses the standard of breadth when judging the group's thinking?

"Is there another way to look at this situation?"

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."

Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)?

A client report of shooting pain up the left leg

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?

Activity and rest

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

Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats

Which behaviors are characteristic of a nurse who is a critical thinker? Select all that apply.

Alert to context so that the need for modification can be identified and changes to the plan of care can be made Responsible and accountable for own actions

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?

Analyze the data and create an individualized nursing diagnosis.

A nurse is educating a pregnant client in preterm labor on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn?

Anxiety

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

Assess the client's back visually.

A nurse technician is assigned to take clients' vital signs. When making rounds, the nurse notices that one client's vital signs are very different from what they were at the beginning of the shift. What is most appropriate for the nurse to do about these findings?

Assess the client's vital signs again.

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

Put the phases of the nursing process in the correct order.

Assessment Diagnosis Planning Implementation Evaluation

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which nursing intervention best demonstrates caring in this situation?

Assisting the client to sit up in a chair

For nursing students to be successful in their educational endeavors, they must

Be actively involved with the material in the text

Which are characteristics of a critical thinker? Select all that apply.

Being open to all points of view Resisting easy answers to client problems Thinking outside the box

Which statements are true about the implementation phase of the nursing process? Select all that apply.

Care provided during implementation should be documented in the client's chart. Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health.

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

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

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking?

Clarity

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented?

Clinical reasoning

Recording prioritized outcomes in the plan of care ensures which benefit?

Continuity of care can be provided to the client.

A nurse is involved in selecting the appropriate nursing diagnosis for a client. Which techniques would the nurse likely use? Select all that apply.

Cue clustering Cluster interpretation Diagnostic validation

Which action exemplifies the purpose of evaluation in the nursing process?

Decide whether to continue, modify, or terminate client care.

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Determine whether the prescribed treatment was effective.

Which action should the nurse associate with outcome identification and planning in the nursing process?

Develops an individualized plan of nursing care

Which step of the nursing process involves reporting or analysis of data to identify and define health problems?

Diagnosis

A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment?

Document this assessment based on the client's behaviors.

When using the nursing process, the nurse notes that there is a great deal of overlapping of the steps, with each step flowing into the next. What is the term for this characteristic of the nursing process?

Dynamic

A hospital client has an aggressive fungal infection in the right eye that necessitates evisceration (removal of the eye). Consequently, the client requires twice-daily packing and dressing changes to the orbit. Which of the nurse's actions in the care of this client most clearly demonstrates interpersonal skills?

Ensuring the client's privacy during dressing changes and providing an explanation during the procedure

The nurse assesses a client's blood pressure, which is 160/90 mm Hg. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure, finding it to be 140/78 mm Hg. Which action has the nurse implemented?

Evaluating

The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What should the nurse determine this phase will include? Select all that apply

Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client's record. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.

Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing practice 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 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

Giving medication occurs in which step of the nursing process?

Implementation

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill?

Intellectual

Which statement best conveys the role of intuition in nurses' problem solving?

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

Which is a characteristic of person-centered care?

It is a framework for providing care.

Which statement regarding critical thinking in nursing is true?

It is a systematic way of thinking.

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next?

Modify the plan of care and interventions to meet the client's needs.

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.

Which is the most appropriate example of the assessment phase of the nursing process?

Palpating a mass in the right lower quadrant of the abdomen

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process?

Planning

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

Planning; implementing

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

Prioritize the nursing diagnoses.

Which is the best example of person-centered care provided by a registered nurse?

Reassuring a client who is anxious about a procedure

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next?

Recheck the temperature, paying close attention to technique.

In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged?

Reevaluating experience in light of ideas

The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action?

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?

Reflection

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?

Repositioning the client

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis?

Risk for falls

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

Which are characteristics of one who has developed critical thinking skills?

Self-aware, honest, persistent, and authentic

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

Show respect for the client, and engage in open communication in getting to know the client.

The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as

Supervisory

Which intervention is most appropriate for a client newly diagnosed with diabetes and a nursing diagnosis of Deficient Knowledge?

Teach the client how to administer insulin.

The nurse is caring for a mother and newborn baby couplet. The mother has a nursing diagnosis of insufficient breast milk but wants to continue to breast feed. The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the baby is gaining weight. What is the most appropriate action by the nurse at this time?

Terminate the plan of care because evaluation reveals that the outcome has been met.

The ability to communicate clearly through documentation is a critical nursing skill. Which statements accurately describe the role of documenting in the nursing process? Select all that apply.

The client record is the chief means of communication among members of the interdisciplinary team. A nursing action not documented is a nursing action not performed. It is helpful to practice documentation while learning any given nursing activity. The content of the client report and nursing documentation helps to establish nursing priorities in practice.

The nurse is preparing to document the nursing diagnoses for a client. What is the most appropriate outcome for the nursing diagnosis of impaired gas exchange?

The client will maintain a pulse oximeter reading of greater than 94% (0.94 L).

The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use?

Trial-and-error problem solving

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:

complete the postoperative assessment.

An obese client is in the clinic to start on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for the client? The client will:

create an exercise plan that is realistic and valued.

The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately states, "This client is getting worse." This is an example of the experienced nurse using:

intuitive problem identification.

A client newly diagnosed with diabetes has been sent home after in-depth education regarding the diabetes management plan. Because the client is newly diagnosed, the nurse included in the plan of care a risk for unstable glucose. What is the most appropriate short-term outcome for this nursing diagnosis in the client? The client will:

maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L).

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified:

outcome.

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.

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

uses critical thinking to direct care for the individual client.