Nursing Process #1

When establishing realistic goals, the nurse: A. Bases the goals on the nurse's personal knowledge. B. Knows the resources of the health care facility, family, and the client. C. Must have a client who is physically and emotionally stable. D. Must have the client's cooperation.

B

For clients to participate in goal setting, they should be: A. Alert and have some degree of independence. B. Ambulatory and mobile. C. Able to speak and write. D. Able to read and write.

A

The nursing care plan is: A. A written guideline for implementation and evaluation. B. A documentation of client care. C. A projection of potential alterations in client behaviors D. A tool to set goals and project outcomes.

A

To initiate an intervention the nurse must be competent in three areas, which include: A. Knowledge, function, and specific skills B. Experience, advanced education, and skills. C. Skills, finances, and leadership. D. Leadership, autonomy, and skills.

A

Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: A. Plan is developed for nursing care. B. Physical assessment begins C. List of priorities is determined. D. Review of the assessment is conducted with other team members.

A- (next in the Nursing Process)

The nurse is most likely to collect timely, specific information by asking which of the following questions? A. "Would you describe what you are feeling?" B. "How are you today?" C. "What would you like to talk about?" D. "Where does it hurt?"

A: Rationale: This is an open-ended question that will elicit subjective data. The data collected will reflect the client's current health status and human response(s) and should generate specific information that can be used to identify actual and/or potential health problems. Options 2 and 3 are more likely to elicit general, nonspecific information. Option 4 may result in a brief, one-word response or nonverbal gesture indicating the site of the client's pain. A better approach to collect specific information might be, "Describe any pain you are having."

The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior B. Conditions or modifiers C. Performance criteria D. Target time

D: Rationale: The outcome goal does not state the target timeframe for when the nurse should expect to see the client behavior ("transfer"). The condition or modifier is present ("with two assists"). The performance criterion is "from bed to chair."

The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? A. A client who is ambulatory. B. A client, who has a fever, is diaphoretic and restless. C. A client scheduled for OT at 1300. D. A client who just had an appendectomy and has just received pain medication.

B

The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? A. A client's family attending a diabetic teaching session. B. Canceling physical therapy sessions on the weekend. C. Normal VS and absence of wound infection in a post-op client. D. A client demonstrating accurate medication administration following teaching.

B

When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: A. Apply a cold pack to the tibia. B. Elevate the leg 5 inches above the heart. C. Perform range of motion to right leg every 4 hours. D. Administer aspirin 325 mg every 4 hours as needed.

B

When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: A. Length of time the current treatment has been in place. B. The spouse's reaction to the client's dressing change. C. Client's concern about the current treatment. D. Physician's reluctance to change the current treatment plan.

A

The nurse assigned to care for a postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? A. Assess the client to be sure ambulation with assistance is an appropriate care measure B. Ask the client if he or she is ready to ambulate C. Ask whether the UAP has time to assist the client D. Ask the charge nurse whether UAPs have ambulated the client

A: Rationale: Prior to delegating any client care responsibilities, the nurse must assess the client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4 would not constitute an assessment of the client's current status.

When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards B. Compare the reading with one taken in the opposite arm C. Determine gaps in the vital signs in the client record D. Compare the current measurement with previous ones

A: Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older adult. The nurse compares the client's data against identified standards to determine whether this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to previous ones (option 4) will give additional client data, but the comparison alone will not determine whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current measurement.

A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, "I'm tired of being sick. I wish I could end it all." What is the most accurate and informative way to record this data in a nursing progress note? A. Client appears to be depressed, possibly suicidal B. Client reports being tired of being ill and wants to die C. Client does not want to live any longer and is tired of being ill D. Client states, "I'm tired of being sick. I wish I could end it all."

D: Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client B. Nurse reviews the client's history on the medical record C. Nurse explains to the client the purpose of each administered medication D. Nurse rapidly reset priorities for client care based on a change in the client's condition

D: Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process.

Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client's: A. Physician B. Non Emergent, non-life threatening needs C. Future well-being. D. Urgency of problems

D

A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation

A: Rationale: The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data.

A client centered goal is a specific and measurable behavior or response that reflects a client's: A. Desire for specific health care interventions B. Highest possible level of wellness and independence in function. C. Physician's goal for the specific client. D. Response when compared to another client with a like problem.

B

As goals, outcomes, and interventions are developed, the nurse must: A. Be in charge of all care and planning for the client. B. Be aware of and committed to accepted standards of practice from nursing and other disciplines. C. Not change the plan of care for the client. D. Be in control of all interventions for the client.

B

While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? A. Help client into the chair but more quickly B. Document client's vital signs taken just prior to moving the client C. Help client back to bed immediately D. Observe client's skin color and take another set of vital signs

D: Rationale: Assessment is ongoing throughout the nurse-client relationship. During re-assessment, the nurse collects additional data to help evaluate the status of problems or identify new problems. Options 1, 2, and 3 are interventions.

Which of the following items of subjective client data would be documented in the medical record by the nurse? A. Client's face is pale B. Cervical lymph nodes are palpable C. Nursing assistant reports client refused lunch D. Client feel nauseated

D: Rationale: Subjective data includes the client's sensations, feelings, and perception of health status. Subjective data can only be verified by the affected person. Options 1, 2, and 3 represent objective data that can be detected by the nurse or measured against an accepted norm.

Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? A. Diagnosis B. Planning C. Implementation D. Evaluation

D: Rationale: Evaluating is the process of comparing client responses to the outcome goals to determine whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks, and strengths. Planning is the formulation of client goals and nursing strategies (interventions) required to prevent, reduce, or eliminate the client's health problems. Implementing is carrying out or delegating the nursing interventions.

The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team? A. Use Liquid PaperTM to "white out" the resolve diagnosis on the care plan B. Recopy the care plan without the resolve diagnosis C. Write a nursing process not indicating that the outcome goals have been achieved D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date

D: Rationale: To discontinue a diagnosis once it has been resolved, cross it off with a single line or highlight it, then write initials and date. Some agency forms may require the nurse to put date and initials in a "Date Resolved" column. Using Liquid PaperTM is not a legal way to amend client records. Outcome goals that have been met and nursing diagnoses that have been resolved should be documented on the care plan. A progress note should also be written, but a single note may not be read by all health team members.

The planning step of the nursing process includes which of the following activities? A. Assessing and diagnosing B. Evaluating goal achievement. C. Performing nursing actions and documenting them. D. Setting goals and selecting interventions

D

The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source B. Subjective data from a secondary source C. Objective data from a primary source D. Objective data from a secondary source

A "Client states... feels..." Coming from the client= Primary

Which of these is a correctly stated outcome goal written by the nurse? A. The client will walk 2 miles daily by March 19 B. The client will understand how to give insulin by discharge C. The client will regain their former state of health by April 1 D. The client achieve desired mobility by May 7

A: Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option 1 is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19).

Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)? A. Taking vital signs of clients on the nursing unit B. Assisting the physician with an invasive procedure C. Adjusting the rate on an infusion pump D. Evaluating achievement of client outcome goals

A: Rationale: Part of the professional nurse's role is to delegate responsibility for activities while maintaining accountability. The nurse must match the needs of the client with the skills and knowledge of UAPs. Certain skills and activities, such as those in options 2, 3, and 4, are not within the legal scope of practice for a UAP

The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following? A. Incomplete data B. Generalize from experience C. Identifying with the client D. Lack of clinical experience

A: Rationale: To collect data accurately, the client must actively participate. Incomplete data can lead to inappropriate nursing diagnosis and planning. The other options are not relevant to the question as presented.

During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?" A. Introduction B. Body C. Closing D. Orientation

A: Rationale: Asking about the weather initiates the social or introductory phase of the interview and allows the nurse to begin an assessment of the client's mental status. The goal is to develop rapport with the client at the beginning of the interview. In the body the client responds to the nurse's questions. During the closing the nurse or the client terminates the interview.

The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

B: Rationale: The planning step of the nursing process involves formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a client's human response, and once a plan is established, the interventions are implemented (option 3) and evaluated (option 4).

The nurse should avoid asking the client which of the following leading questions during a client interview? A. "What medication do you take at home?" B. "You are really excited about the plastic surgery, aren't you?" C. "Were you aware I've has this same type of surgery?" D. "What would you like to talk about?"

B: Rationale: A leading question directs the client's answer. The phrasing of the question indicates an expected answer. The client may be influenced by the nurse's expectations and may give inaccurate responses. This process can result in an error in diagnostic reasoning.

The nurse would place which correctly written nursing diagnostic statement into the client's care plan? A. Cancer relater to cigarette smoking B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen saturation of 91% C. Imbalance nutrition: more than body requirement related to overweight status D. Impaired physical mobility related to generalized weakness and pain

B: Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human response) names/labels the problem. The second part (related factors) includes the factors that either contribute to or are probable etiologies of the human response. Some formats include a third part to the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms and is joined to the statement with the label as evidenced by. This type of statement is the most complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague.

Which desired outcome written by the nurse is correctly written and measurable? A. Client will have a normal bowel pattern by April 2 B. The client will lose 4 lbs. within next 2 weeks C. The nurse will provide skin care at least 3 times each day D. The client will breathe better after resting for 10 minutes

B: Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Each of the incorrect options lacks one of these required elements. Option 1 is not measurable (not as clear as option 2). Option 3 is a nursing goal rather than a client goal. Option 4 does not include the level at which the behavior should be performed.

The client reports nausea and constipation. Which of the following would be the priority nursing action? A. Collect a stool sample B. Complete an abdominal assessment C. Administer an anti-nausea medication D. Notify the physician

B: Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a completed assessment.

The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight and age. The nurse should take which of the following actions? A. Administer the medication as ordered by the prescriber B. Call the prescriber to discuss the order and the nurse's concern C. Administer the medication, but chart the nurse's concern about the dosage D. Give the client half the dosage and document accordingly

B: Rationale: Client safety is of the utmost importance when implementing any nursing intervention. If the nurse feels that an order is unsafe or inappropriate for a client, the nurse must act as a client advocate and collaborate with the appropriate healthcare team member to determine the rationale for the order and/or modify the order as necessary. A nurse accepts accountability for his or her actions. Options 1, 3, and 4 are inappropriate and unsafe.

When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B. Suggesting the medication can be diluted in a beverage C. Asking the nurse manager about how to approach the situation D. Notifying the physician inability to give the client this medication

B: Rationale: Diluting the medication in a beverage may make the medication more palatable. Using critical thinking skills, the nurse should try to problem-solve in a situation such as this before asking for the assistance of the nurse manager. Suggesting an alternative method of taking the medication (provided that there are no contraindications to diluting the medication) should improve the likelihood of the client taking the medication.

The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired/expected outcomes should the nurse include in the care plan? A. Client will be able to turn self by day 3 B. Skin will remain intact and without redness during hospital stay C. Client will state pain relieved within 30 minutes after medication D. Pressure will be prevented by repositioning client every 2 hours

B: Rationale: The human response/label is what needs to change (Risk for impaired skin integrity). The label suggests the outcomes. In this case, "skin will remain intact" is the desired outcome for a client at risk for impaired skin integrity. Option 1 addresses immobility. Option 3 addresses pain. Option 4 is an intervention.

The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a nursing diagnosis of impaired gas exchange B. Record in the medical record the distance a client ambulate in the hall C. Write individualized nursing orders in the care plan D. Compare client responses to the desired outcomes for pain relief

B: Rationale: The implementation phase of the nursing process involves carrying out or delegating the nursing interventions and recording nursing activities and client responses in the medical records. Option 1 represents diagnosing. Option 3 represents planning. Option 4 represents evaluation.

The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B. The client's urine output was 450 mL C. The client states, "I didn't see any stones in my urine." D. The client states, "I feel like I have passed a stone."

B: Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse. The objective data is the measurement of the urine output. A client's statements and reports of symptoms are documented as subjective data, such as the data found in options 1, 3, and 4.

Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis? A. Grimacing B. Anxiety C. Oxygenation saturation 93% D. Output 500 mL in 8 hours

B: Rationale: The problem part of a nursing diagnosis should state the client's response to a life process, event, or stressor. These are categorized as nursing diagnoses. The incorrect options are cues the nurse would use to formulate the nursing diagnostic statement.

The nurse writes an expected outcome statement in measurable terms. An example is: A. Client will have less pain. B. Client will be pain free. C. Client will report pain acuity less than 4 on a scale of 0-10. D. Client will take pain medication every 4 hours around the clock.

C

Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge E. Client will be medicated every 4 hours by the nurse

C & D: Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal.

Planning is a category of nursing behaviors in which: A. The nurse determines the health care needed for the client. B. The Physician determines the plan of care for the client. C. Client-centered goals and expected outcomes are established. D. The client determines the care needed.

C (SMART goals & in agreement of all parties involved)

After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. A. Constipation B. Anticipated grieving C. Ineffective airway clearance D. Ineffective tissue perfusion.

C,D,A,B

Which nurse is demonstrating the assessment phase of the nursing process? A.The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals

C: Rationale: Assessment involves collecting, organizing, validating, and documenting data about a client. Option 1 represents the evaluation phase. Option 2 represents the implemention phase. Option 4 represents the planning phase.

Well formulated, client-centered goals should: A. Meet immediate client needs. B. Include preventative health care. C. Include rehabilitation needs. D. All of the above.

D

In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important? A. Set incremental goals for blood pressure reduction B. Instruct the client to make dietary changes by reducing sodium intake C. Include the client and family when setting goals and formulating the plan of care D. Assess past compliance to medication regimens

C: Rationale: In developing a plan of care, nurses engage in a partnership with the client and family. Nurses do not plan care for clients; instead they plan care with clients and families. Assessment (option 4), goal setting (option 1), and interventions (option 2) will be most accurate and effective when carried out in partnership with the client and family. The other options represent other actions to take, but they will have less overall effectiveness if the client and family are not part of the plan.

The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis

C: Rationale: The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome.

The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein intake C. Risk for impaired skin integrity related to malnutrition D. Impaired nutrition related to current illness

C: Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or less than body requirements) and is therefore incomplete. It also does not provide direction for development of goals and interventions.

Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? A. Use the previous, less restrictive policy conscientiously B. Express immediate disagreement with the new policy C. Ask for the rationale behind the new policy D. Obey the policy but continue to voice disapproval of it to co-workers

C: Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed change and understand its purpose. Options 1, 2, and 4 represent unprofessional behavior. Option 1 also places a client's safety at risk.

The nurse needs to validate which of the following statements pertaining to an assigned client? A. The client has a hard, raised, red lesion on his right hand. B. A weight of 185 lbs. is recorded in the chart C. The client reported an infected toe D. The client's blood pressure is 124/70. It was 118/68 yesterday.

C: Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse should assess the client's toe to validate the statement.

After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: A. Encourage client to implement guided imagery when pain begins. B. Determine effect of pain intensity on client function. C. Administer analgesic 30 minutes before physical therapy treatment. D. Pain intensity reported as a 3 or less during hospital stay.

D

Collaborative interventions are therapies that require: A. Physician and nurse interventions. B. Nurse and client interventions. C. Client and Physician intervention. D. Multiple health care professionals.

D

In giving a change-of-shift report, which type of client information communicated by the nurse is most appropriate? A. Vital signs are stable B. Client is pleasant, alert, and oriented to time, place, and person C. The chest x-ray results were negative D. Client voided 250 mL of urine 2 hours after the urinary catheter removal

D: Rationale: A change-of-shift report should include significant changes (good or bad) in a client's condition. The information should be accurate, concise, clear, and complete. Options 1 is vague and options 2 and 3 are normal data and are therefore of lesser importance to convey in the change-of-shift report.