PrepU Questions: Week 7-- Nursing Process

Several times, family members have asked a nurse to share personal prescriptions when they were in need of pain medication or antibiotics. Which type of rules or standards should govern the nurse's moral decision?

ethics

The nurse checks a client's temperature before administering a standing prescription for acetaminophen for temperatures over 100°F (37.8°C). The client's temperature is 98.9°F (37.2°C), so the nurse decides to withhold the dose of acetaminophen. Withholding the dose represents which phase of the nursing process?

implementation

A client with newly diagnosed diabetes requests information about how to give an injection. What is the best communication technique the nurse can use with the client?

informing about the proper injection technique

Which type of nursing diagnosis identifies an existing condition that the client is experiencing?

problem-focused

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 nurse is planning to educate a client about medication therapy. What is an essential part of the nursing process?

that the nurse perform all teaching and evaluation

A nurse using critical thinking interprets data and determines appropriate interventions. What factor will affect the nurse's ability to employ critical thinking with data interpretation?

the nurse's personal biases

A client presents to the acute care facility with several signs and symptoms. How will the nurse determine and prioritize the client's healthcare needs?

using a systematic method to plan and implement care to reach desired outcomes

A nurse saw a coworker steal drugs from a locked cabinet. The supervisor notices the missing drugs and has a good idea who is responsible for the theft. The supervisor asks if the nurse saw anything out of the ordinary. Which professional value reflects a nurse's duty to tell the truth?

veracity

The RN develops an outcome standard of "client will ambulate with an assistive device 60 feet with assistance twice a day" for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?

Planning

Place the steps of the nursing process in the proper sequence from first to last. Use all options.

-Assessment -Analysis -Planning -Implementation -Evaluation

The nurse is creating a concept map to plan for the care of a client. Place in order the steps the nurse will perform to create the concept map.

-Collect client problems and concerns on a list. -Connect and analyze the relationships. -Create a diagram. -Keep in mind key concepts. -Apply the concept map to client care.

A terminally ill client asks the nurse, "Am I dying?" The family has asked the health care team not to disclose the client's terminal illness. What is the best action by the nurse with the client's question? Select all that apply.

-Communicate the client's wishes to the family. -Consult with the health care provider -Provide correct information 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

In discussing the drug regimen with the client, what factors should be included? (Select all that apply.)

-Length of time before desired therapeutic effect will occur -Steps to minimize adverse reactions -Adverse reactions to expect

The nurse knows that a framework that uses a language common to all aspects of nursing, regardless of the classification system, is desirable. In 2001, a taxonomy of nursing practice was developed and includes which of the following? Choose all that apply.

-NANDA -NIC -NOC

A client is confused about advance directives and asks the nurse to explain them. What information will the nurse include in client teaching about advance directives? Select all that apply.

-They provide information about client wishes for health care situations. -They may contain a living will.

During review of a plan of care for a client, the nurse determines that the outcomes have not been achieved. The nurse believes an error may have been made during the planning phase of the nursing process. Based on this belief, what will the nurse consider during this evaluation step? Select all that apply.

-Was the appropriate nursing diagnosis chosen? -Do the nursing interventions need revision? -What factors led to the achievement of the outcomes? -Have new problems evolved requiring different interventions? -Were the time frames appropriate to achieve the expected outcomes?

Which information is necessary when planning discharge for the client? (Select all that apply.)

-social supports -financial supports -client self-care ability

Which critical thinking skill involves identification of client problems indicated by data?

Analysis

The health care provider orders NPH U100 insulin 16 units SC every AM for a client. The nurse prepares the insulin dose. To ensure safety, what does the nurse do?

Ask another nurse to double-check the measurement.

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.

While caring for a client with a deep vein thrombosis of the leg, the nurse monitors for collaborative problems. Which action will the nurse implement while treating collaborative problems for this client?

Assess the respiratory status every 4 hours.

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

The nurse is administering a medication to a client for the treatment of his constipation. The client states that he prefers not to take the medication today. The nurse respects the client's right and informs him if he needs it later, just let the nurse know. What professional value is the nurse displaying?

Autonomy

The nurse is caring for a terminally ill client in the intensive care unit that is on life support measures. The family members are opposed in their decision to take the client off of life support. What option does the nurse discuss with the nurse manager?

Contact the ethics committee for their input.

Analyzing information for patterns, maintaining a flexible attitude, and making decisions reflecting creativity are all what type of components necessary for nurses?

Critical thinking

A client has designated her daughter as a person to make healthcare decisions for the client if he is not able to do so. What type of advance directive is this considered?

Durable power of attorney (DPOA) for healthcare

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 client reports postoperative pain near the incision site on his abdomen. He describes the pain as constantly burning and rates it at an 8/10 using the pain scale. The nurse administers morphine sulfate 2 mg IVP as ordered. Ten minutes later the nurse documents that the client now rates his pain at a 3/10 using the pain scale. The nurse's documentation is an example of which part of the nursing process?

Evaluation

Effectiveness of medication therapy is associated with which phase of the nursing process?

Evaluation

The nurse knows it is important to individualize prewritten interventions to promote optimal effectiveness for each client. Actions of nurses should be based on established standards. What is the name of the organization that is a standardized classification system of nursing interventions?

NIC

Which type of nursing diagnosis is a clinical judgment of a client's motivation and behavior to increase his or her well-being?

Health promotion

Which element is involved in the planning phase of the nursing process?

Identify measurable outcomes

Which communication technique is helpful in health teaching about relevant aspects of a client's well-being and self-care?

Informing

Which statement regarding critical thinking in nursing is true?

It is a systematic way of thinking.

Which instruction would be most appropriate for the nurse to teach the client to reduce the risk of medication related injuries in the home setting?

Know what each drug is being used for as treatment.

A 7-year-old child fell off a wood pile while playing and has been admitted to the ICU with multiple broken bones and internal bleeding. What factor related to drug therapy will be altered in this client?

Pharmacodynamics may be altered.

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 nursing intervention would the nurse expect to do during implementation?

Providing client teaching about a drug therapy regimen.

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

What is the primary purpose associated with the use of the nursing process related to the implementation of medication therapy?

That holistic, evidence-informed care is given

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 just returned to the unit following abdominal surgery and is in significant pain. According to the nursing process, how frequently will the nurse perform assessments on this client?

as often as needed.

A nurse is caring for a client who is prescribed multiple medications. Which clients are most likely to have adverse drug reactions?

clients who are very young or very old

Several days this week, a nurse takes time after work to read to a visually impaired client who has no family close by. This behavior demonstrates that ethical values:

concern the treatment of others.

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.