The Nursing Process PrepU

What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?

Bone marrow transplantation

A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?

Bowel Incontinence

The nurse is admitting a 12-year-old child diagnosed with osteomyelitis of the left femur. What will be the nurse's first action for the child's care?

Draw blood for cultures as ordered.

A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube?

"The ET tube will maintain your airway while you're under anesthesia."

A client is scheduled for a transurethral rescection of the prostate (TURP). Which statement demonstrates that the expected outcome of "client demonstrates understanding of the surgical procedure and aftercare" has been met?

"The surgeon is going to insert a scope through my urethra to remove a portion of the gland."

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority?

Assign a female nurse to care for her.

The nurse is providing care to a client who has had a kidney biopsy. The nurse would need to be alert for signs and symptoms of which of the following?

Bleeding

Which step of the nursing process determines whether the client understands the health teaching that is provided?

Evaluation

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client?

Impaired gas exchange

The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse's next step in correcting this problem?

Make changes in the plan of care based upon assessment data.

A patient diagnosed 2 weeks ago with acute pharyngitis comes to the clinic stating that the sore throat got better for a couple of days and is now back along with an earache. What complications should the nurse be aware of related to acute pharyngitis? (Select all that apply.)

Mastoiditis Otitis media Peritonsillar abscess

The nurse working in the recovery room is caring for a client who had a radical neck dissection. The nurse notices that the client makes a coarse, high-pitched sound upon inspiration. Which intervention by the nurse is appropriate?

Notify the physician; The presence of stridor, a coarse, high-pitched sound upon inspiration, in the immediate postoperative period following radical neck dissection, indicates obstruction of the airway, and the nurse must report it immediately to the physician.

A client has begun taking an antidepressant that causes the client to be drowsy. What nursing diagnosis should the nurse prioritize related to drug therapy?

Risk for injury

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury

A client comes to a health care facility reporting abdominal pain and vomiting. The client's spouse informs the nurse that the client went out for dinner the previous night. The report that the client went out for dinner the previous night is example of data from which type of source?

Secondary

An appropriate nursing diagnosis for a bedridden hospitalized client who tells the nurse that he has not missed a Methodist church service in 50 years would be:

Spiritual Distress related to inability to attend church services evidenced by verbal states of guilt

The nurse administers hydrocortisone cypionate (Cortef). What intervention is appropriate for this medication?

The nurse will monitor the patient's blood glucose level.

A nurse explains to a client what he will typically see, hear, and feel during his scheduled surgery. The nurse is engaged in:

sensation information.

The nurse admits a 10-year-old who has just eaten lobster and has hives over much of the body. In collecting data regarding this child, which question should the nurse ask the caregiver first?

"Has the child ever eaten shellfish before now?"

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?

1000; Postpartum hemorrhage is defined as blood loss of 500 mL or more after a vaginal birth and 1000 ml or more after a cesarean birth.

A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?

Acidic

The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care?

Advice for the family to have fruit juices readily available at the client's bedside.

A nurse documents a client's hemoglobin as 80 g/L. What nutritional condition does this biochemical data signify?

Anemia; If hemoglobin (normal = 12 to 18 g/dL; 120 to 180 g/L) is decreased, anemia is present. A increased hematocrit signifies dehydration. Malnutrition is related to serum albumin, blood urea nitrogen, and creatinine. Decreased serum albumin also signifies malabsorption.

A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis is appropriate for this client?

Anticipatory grieving

A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?

Call the health care provider immediately.

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?

Count the rate of respirations.

Following a voiding cystogram, the client has a nursing diagnosis of risk for infection related to the introduction of bacterial following manipulation of the urinary tract. An appropriate nursing intervention for the client is to:

Encourage high fluid intake.

A client who is taking an estrogen reports swelling and weight gain. The nurse notes some peripheral edema. Which nursing diagnosis would the nurse identify as the priority?

Fluid volume excess

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to circumferential eschar

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and she believes she is in a hotel. How should the nurse best respond to this client's disorientation?

Reorient the client to place and time.

The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client?

Risk for Impaired Parenting

The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is:

Risk for ineffective therapeutic regimen management

Which nursing diagnosis is most appropriate for a client with Addison's disease?

Risk for infection

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

The postoperative patient's plan of care contains an intervention to ambulate twice a day 200 feet with assistance of one member of the healthcare team. The intervention was not completed one morning due to his pain. Which of the following would be the appropriate way to document the missed event?

The patient reported his pain at a level of 8/10 at 30 minutes after dosing. The patient was returned to bed and the physician was notified of the uncontrolled pain level with the current medication order.

A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?

Type II; There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area but are responsible for producing type I cellsand surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. Type IV is not a category of alveolar cells.

Which of the following is considered the gold standard for the diagnosis of liver disease?

Biopsy

The nurse is caring for a client who had undergone hemodilution during surgery. Immediately after surgery, the nurse expects to see which lab result?

Decreased hematocrit

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance?

Demonstrating control over aggressive behavior

The nurse is caring for a client who is exhibiting symptoms of tachypnea and circumoral paresthesias. What should be the nurse's first course of action?

Find and correct the cause of tachypnea.

A client experiencing acute alcohol withdrawal is upset about going through detoxification. Which goal should be the priority for the nurse?

The client will work with the nurse to remain safe.

A nurse notices that a client with obsessive-compulsive disorder washes the hands for long periods each day. How should the nurse respond to this compulsive behavior?

by setting aside times during which the client can focus on the behavior

A client requests medication at 9 p.m. (2100) instead of 10 p.m. (2200) so that the client can go to sleep earlier. Which type of nursing intervention is required?

independent; Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already ordered drug on time is a dependent intervention. There's no such thing as an intradependent nursing intervention.

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount?

moderate