Fundamentals Chapter 16 PREPU Questions

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

"Client will identify one coping strategy to try by end of week."

Which are characteristics of appropriate client outcome statements? Select all that apply.

- Realistic - Specific - Measurable

These nursing diagnoses appear on a client's care plan. Place in the order in which the nurse will prioritize acting upon them. Use all options.

1. Impaired Swallowing 2. Fluid Volume deficit 3. Risk for Impaired Skin Integrity 4. Altered Body Image

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

Which is an appropriate expected outcome for a client?

Client will ambulate safely with walker in the room within 3 days of physical therapy.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

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.

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.

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 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 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 describes what the researchers are examining?

Outcome

What are specific measurable and realistic statements of goal attainment?

Outcomes

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.

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

Psychomotor

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

Selects nursing measures, including client education

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.

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.

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.

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

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)

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

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.

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

discharge planning.

The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually

does not contain documented scientific rationales.

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.

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."

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

Identify measurable goals or outcomes.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

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.

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 primary purpose of developing expected client outcomes is to:

provide individualized care.

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?

"Please tell me your thoughts about treating this diagnosis."

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.

The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. When completing the plan of care, which outcome is written the clearest for working with the multidisciplinary team?

By discharge from the fertility clinic, the client will achieve full-term pregnancy.

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normotensive.

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 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

Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal?

Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender.

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.