Ch 1, 13, 14, 15, 16, 17, 18, 19

A nurse has come on day shift and is assessing the client's intravenous setup. The nurse notes that there is a mini-bag of the client's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the patient's medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is three hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which of the following? A) Ethical/legal skills B) Technical skills C) Interpersonal skills D) Cognitive skills

Ans: A Feedback: Reporting problems and unacceptable practices is an aspect of ethical/legal skills. Technical skills enable the safe performance of kinesthetic tasks while interpersonal skills are the manifestations of caring. Cognitive skills encompass knowledge and critical thinking.

Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes? A) The nurse expresses the client outcome as a nursing intervention. B) The nurse develops measurable outcomes using verbs that are observable. C) The nurse develops a target time when the client is expected to achieve that outcome. D) The outcome should include a subject, verb, conditions, performance criteria, and target time.

Ans: A Feedback: A common error made when writing client outcomes includes the nurse expressing the client outcome as a nursing intervention. The other mentioned criteria for writing client outcomes are correct.

Ch 16 The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal? A) Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. B) By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma. C) Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased. D) Within 72 hours of admission, the client's respiratory rate returns to normal and retractions disappear.

Ans: A Feedback: An example of a long-term outcome is "Patient returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack." The other three examples are short-term outcomes that focus on short-term goals related to the period of time during hospitalization.

A client comes to the emergency department complaining of severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating? A) Assessing B) Diagnosing C) Planning D) Implementing

Ans: A Feedback: Assessing is the step in which nurses assess the client to determine the need for nursing care. When assessing, the nurse systematically collects client data.

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs? A) Physiologic B) Safety C) Love and belonging D) Self-actualization

Ans: A Feedback: Because basic human needs must be met before a person can focus on higher-level needs, client needs may be prioritized according to Maslow's hierarchy. Physiologic needs, including the need for oxygen, are the most basic and have the highest priority.

Which intervention does the nurse recognize as a collaborative intervention? A) Teach the client how to walk with a three-point crutch gait. B) Administer spironolactone (Aldactone). C) Perform tracheostomy care every eight hours. D) Straight catheterize every six hours.

Ans: A Feedback: Collaborative interventions are treatments initiated by other providers, such as pharmacists, respiratory therapists, physical therapists, and other members of the health care team. Teaching the client how to walk with crutches would be a collaborative intervention. Administering medications, performing tracheostomy care, and catheterizing a client require a physician's order and are physician-initiated interventions.

What is a systematic way to form and shape one's thinking? A) Critical thinking B) Intuitive thinking C) Trial-and-error D) Interpersonal values

Ans: A Feedback: Critical thinking is defined as "a systematic way to form and shape one's thinking. It functions purposefully and exactingly. It is thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned" (Paul, 1993, p. 20).

A male client is scheduled to be fitted with a prosthesis following the loss of his nondominant hand in a farm accident several weeks earlier. Nurses have documented the following outcome during this stage of his care: "After attending an educational session, client will demonstrate correct technique for applying his prosthesis." Which of this client's following statements would signal a need to amend this outcome? A) "I'm not interested one bit in wearing an artificial hand." B) "I'm worried that I'm going to get some really strange looks when I wear this thing." C) "I don't have a clue how this thing goes on and comes off." D) "I don't understand the technology that's used in this artificial hand."

Ans: A Feedback: It is imperative that interventions and outcomes be valued by the client. The client's resistance to using a prosthesis likely invalidates the outcome that addresses his technique for its use. The other statements express cognitive and affective learning needs that would need to be addressed, but none of those precludes his eventual mastery of the prosthesis.

What common problem is related to outcome identification and planning? A) Failing to involve the client in the planning process B) Collecting sufficient data to establish a database C) Stating specific and measurable outcomes based on nursing diagnoses D) Writing nursing orders that are clear and resolve the problem

Ans: A Feedback: One of the most important considerations in outcome achievement is to encourage the client and family to be as involved in goal development as their abilities and interest permit. The more involved they are, the greater the probability that the outcomes will be achieved.

A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which of the following aspects of the nurse's execution of this order demonstrates technical skill? A) Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing B) Understanding the Rh system that underlies the client's blood type C) Ensuring that informed consent has been obtained and properly filed in the client's chart D) Explaining the process that will be involved in preparing and administering the transfusion

Ans: A Feedback: Performing tasks that require manual dexterity is a manifestation of technical skills. Explaining the transfusion process is largely dependent on interpersonal skills while understanding the theory behind blood types is indicative of cognitive skills. Informed consent lies within the domain of legal/ethical skills.

The nurse is planning the care of a male client who is receiving treatment for acute renal failure and who has begun dialysis three times weekly. The nurse has identified the following outcome: "Client will demonstrate the appropriate care of his arteriovenous fistula." This outcome is classified as which of the following? A) Psychomotor B) Affective C) Cognitive D) Holistic

Ans: A Feedback: Psychomotor outcomes describe the client's achievement of new skills, such as the safe and aseptic care of a new fistula. Cognitive outcomes are focused on knowledge and effective outcomes address values, beliefs, and attitudes. Outcomes are not classified as holistic.

What name is given to standardized plans of care? A) Critical pathways B) Computer databases C) Nursing problems D) Care plan templates

Ans: A Feedback: Standardized care plans include critical pathways, which target desired outcomes for particular illnesses, procedures, or conditions along a timeline. Critical pathways are used in many health care settings.

The nurse is providing care for a pediatric client on night shift. At 0400, the nurse notes that the child has a high fever but does not have an order for an antipyretic. What nursing action represents a good example of teamwork and collaboration as defined by the Quality and Safety Education for Nurses (QSEN) competencies? The nurse: A) calls the health care practitioner, reports her findings, and requests an order for an antipyretic. B) gives the child a common over-the-counter antipyretic based on dosing recommendations and reports this to the oncoming nurse. C) reports to the oncoming nurse at 0700 that the child has a fever so that when the healthcare provider comes in, she can obtain an order for an antipyretic. D) requests that the child 's mother give the child something for the fever that she brought from home.

Ans: A Feedback: Teamwork and collaboration as defined by QSEN indicates the need to recognize practice boundaries at the same time as functioning within the inter-professional team to accomplish shared decision making. It is the nurses responsibility to report altered client status that may require collaborative interventions, irregardless of time of day. For the nurse to administer a medication, there must be a written order for the medication, and it is outside of the scope of practice to prescribe medications. Waiting to report the assessment to an oncoming nurse may delay client care and effect client outcomes. It would be inappropriate to require the mother take care of this with medications brought from home.

When the nurse assesses the client's blood sugar, what is the term for the type of skill the nurse is using? A) Technical B) Therapeutic C) Interactional D) Adaptive

Ans: A Feedback: Technical skills are used to carry out treatments and procedures.

Which of the following groups developed standard language to increase the visibility of nursing's contribution to client care by continuing to develop, refine, and classify phenomena of concern to nurses? A) NANDA B) NIC C) NOC D) HHCC (now CCC)

Ans: A Feedback: The North American Nursing Diagnosis Association (NANDA) International increased the visibility of nursing's contribution to client care by continuing to develop, refine, and classify phenomena of concern to nurses. The Nursing Interventions Classification (NIC) works to identify, label, validate, and classify actions nurses perform, including direct and indirect care interventions. The Nursing-Sensitive Outcomes Classification (NOC) identifies, validates, and classifies nursing-sensitive client outcomes and indicators to evaluate the validity and usefulness of the classification. Home Health Care Classification (HHCC, now known as Clinical Care Classification (CCC) system) provides a structure for documenting and classifying home health and ambulatory care.

Increasingly, health care institutions are implementing computerized plans of nursing care. A benefit of using computerized plans includes which of the following? A) Reduction in the time spent on care planning B) Increased autonomy related to the nursing care planning process C) Enhanced individualization of a care plan D) Increased nursing expertise in care planning

Ans: A Feedback: The benefits of using computerized plans include ready access to a large knowledge base; improved record keeping, with resultant improvement in audits and quality assurance; documentation by all members of the health care team; and reduced time spent on paperwork. Research cautions that computerized systems for client care planning contribute to loss of autonomy, loss of individualization of care, and loss of nursing expertise.

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation? A) Record an evaluative statement in the client's plan of care. B) Remove the outcome from the client's care plan. C) Ask the nurse who wrote the plan of care to document this development. D) Reassess the client's psychomotor skills at dinner time.

Ans: A Feedback: The client has successfully met this outcome, and the nurse should note the time and date that it was achieved in the client's plan of care. The outcome should not be removed from the plan of care and it is unnecessary to have the original author of the plan update it. Further observation may or may not be necessary at dinner time, but an evaluative statement should nonetheless be recorded at the present time.

After completing an assessment of a client, the nurse uses critical thinking and clinical reasoning to prioritize the client's problems. Which of the following would the nurse determine is the highest priority? A) Severe bleeding from a wound B) History of asthma C) Diabetes D) Lack of family support

Ans: A Feedback: The client's problem is considered to be of high priority if it is life-threatening, requires more intervention time, and has serious consequences. The severe bleeding from a wound would be the highest priority. The client's history of asthma, diabetes, and lack of family support may be important but the bleeding is the priority.

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the healthcare facility. The nurse determines the client's priorities for care using which of the following? A) Assessment skills B) Nursing books C) Client's records D) Supervisor's advice

Ans: A Feedback: The nurse should use assessment skills to determine the priority of nursing care for the client. Books on nursing can give only the theoretical aspect of nursing care. Client's records reveal information about the client's condition but do not convey the client's needs. Advice from supervisors can be taken if confronted with a problem.

A client age 50 years reports to a primary care unit with an open wound due to a fall in the bathroom. Which of the following nursing actions represents caring skills? A) The nurse cleans the wound and applies a dressing to it. B) The nurse inspects and examines the wound for swelling. C) The nurse tells the client to use caution while on slippery surfaces. D) The nurse informs the client that the wound is small and will heal easily.

Ans: A Feedback: The nursing action of cleaning the wound and applying a dressing indicates caring skills. The nurse implements assessment skills while inspecting and examining the wound. The nurse counsels the client to use caution when walking on slippery surfaces. By informing the client about the wound's condition, the nurse uses comforting skills.

Ch 13 The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill? A) Cognitive skill B) Technical skill C) Interpersonal skill D) Ethical/legal skill

Ans: A Feedback: The student is demonstrating the use of cognitive skills, which is characterized by identifying scientific rationales for the client's plan of care, selecting nursing interventions that are most likely to yield the desired outcomes, and using critical thinking to solve problems. Technical skills focus on manipulating equipment skillfully to produce a desired outcome. Interpersonal skills are used to establish and maintain a caring relationship. Ethically and legally skilled nurses conduct themselves in a manner consistent with their personal moral code and professional role responsibilities.

A student is asked to perform a skill for which he is not prepared. When using the method of critical thinking, what would be the first step to resolve the situation? A) Purpose of thinking B) Adequacy of knowledge C) Potential problems D) Helpful resources

Ans: A Feedback: The student's first step when thinking critically about a situation is to identify the purpose or goal of the thinking. This helps to discipline thinking by directing all thoughts toward the goal.

In which of the following situations would the nurse be most justified in implementing trial-and-error problem solving? A) The nurse is attempting to landmark an obese client's apical pulse. B) The nurse is attempting to determine the range of motion of a client's hip joint following hip surgery. C) The nurse is attempting to determine which PRN (as needed) analgesic to offer a client who is in pain. D) The nurse is attempting to determine whether a poststroke client has a swallowing deficit.

Ans: A Feedback: Trial-and-error problem solving can be dangerous to the client. Testing range of motion by trial-and-error could result in dislocation; trial-and-error drug administration could result in over- or under-medicating; trial-and-error assessment of a potential swallowing deficit could result in aspiration. Each of these situations warrants more systematic problem-solving. Trial-and-error landmarking of an anatomically difficult point, such as the apex of an obese client's heart, does not pose a threat to the client and a reasonable amount of "hunting" for the apical pulse may be necessary.

CH 1. 1. An oncology nurse with 15 years of experience, certification in the area of oncology nursing, and a master's degree is considered to be an expert in her area of practice and works on an oncology unit in a large teaching hospital. Based upon this description, which of the following career roles best describes this nurse's role, taking into account her qualifications and experience? A) Clinical nurse specialist B) Nurse entrepreneur C) Nurse practitioner D) Nurse educator

Ans: A Feedback: A clinical nurse specialist is a nurse with an advanced degree, education, or experience who is considered to be an expert in a specialized area of nursing. The clinical nurse specialist carries out direct patient care; consultation; teaching of patients, families, and staff; and research. A nurse practitioner has an advanced degree and works in a variety of settings to deliver primary care. A nurse educator usually has an advanced degree and teaches in the educational or clinical setting. A nurse entrepreneur may manage a clinic or health-related business.

Which of the following provides the nurse with the most reliable basis on which to choose a nursing diagnosis? A) A cluster of several significant cues of data that suggest a particular health problem B) A single, definitive cue that is closely associated with a common diagnosis C) A cue that can be verified by objective, medical data D) A group of related nursing diagnoses that exist within the same NANDA-approved domain

Ans: A Feedback: A data cluster is a grouping of client data or cues that points to the existence of a client health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. Medical corroboration is not always possible or necessary. The presence of multiple nursing diagnoses within one domain does not necessarily validate further diagnoses in that same domain.

Ch 17 1. A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the client's discharge needs. This interaction is an example of which professional nursing relationship? A) Nurse-health care team B) Nurse-patient C) Nurse-patient-family D) Nurse-nurse

Ans: A Feedback: A nurse-health care team professional relationship occurs when the nurse coordinates the input of the multidisciplinary team into a comprehensive plan of care. The nurse may also serve as a liaison between the client and family and the health care team, as necessary.

34. A client reports to the emergency department with ankle pain from a minor road accident. The nurse asks the client to fully describe the circumstances of the accident. Which ANA standard of nursing practice is best demonstrated by the nurse's action? A) Assessment B) Diagnosis C) Ethics D) Caring

Ans: A Feedback: According to the ANA Standard I, the registered nurse collects comprehensive data pertinent to the client's health or the situation. Standard 2 - Diagnosis is Standard 2, which occurs when the registered nurse analyzes the assessment data to determine the diagnoses or issues pertaining to the client. Standard 7 - Ethics pertains to the ethical guidelines of nursing practice. Caring, although an essential part of nursing practice, is not considered an ANA Standard.

The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body Requirements in the care of moderately obese client. How should the nurse proceed after writing this diagnosis? A) Validate the nursing diagnosis B) Identify potential complications C) Cross-reference the nursing diagnosis with medical diagnoses D) Modify interventions based on the diagnosis

Ans: A Feedback: After writing a nursing diagnosis, it is important to verify and validate the diagnosis. This action should precede the modification of the client's care. Nursing diagnoses do not always correlate with medical diagnoses and not every nursing diagnosis is accompanied by potential complications.

The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures

Ans: A Feedback: An inference must be followed by a validation process. In this case, the inference of fever is best validated or rejected by measuring the client's temperature. This should precede interventions such as blood work or even providing a warm blanket.

The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures.

Ans: A Feedback: An inference must be followed by a validation process. In this case, the inference of fever is best validated or rejected by measuring the client's temperature. This should precede interventions such as blood work or even providing a warm blanket.

32. The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88, an increase from 134/78 at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care? A) My husband has been ill and I don't have anyone to help me care for him. B) I have learned to prepare foods differently so they are low in fat. C) My neighbor walks with me around the neighborhood every morning. D) I have been taking my hydrochlorothiazide (HydroDIURIL) every day.

Ans: A Feedback: Common factors that contribute to a client not following the plan of care include lack of family support, inability to afford treatment, limited access to treatment, and adverse physical or emotional effects of treatment. The burden of caring for her husband may be placing stress on the client, and causing her blood pressure to be elevated despite engaging in health promotion and blood pressure-lowering activities.

Ch 14 Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients? A) "Assessment data about the client should be collected continuously." B) "Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." C) "Assess your client at least hourly if the client's vital signs are unstable, and every two hours if the vital signs are stable." D) "Assessment data should be collected prior to the physician rounding on the unit."

Ans: A Feedback: Data about the client are collected continuously because the client's health status can change quickly.

26. The Nurse Corps of the United States Army was established by whom? A) Dorothea Dix B) Lillian Wald C) Florence Nightingale D) Isabel Hampton Robb

Ans: A Feedback: Dorothea Dix established the Nurse Corps of the United States Army.

5. A male client 30 years of age is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse's best intervention in this client's care? A) Educate the client about the benefits of early mobilization and offer to assist him. B) Respect the client's wishes to remain in his bed and ask him when he would like to begin mobilizing. C) Show the client the expected outcomes on his clinical pathway that relate to mobilization. D) Document the client's noncompliance and reiterate the consequences of delaying mobilization.

Ans: A Feedback: Educating the client about the benefits of mobilizing, and offering to assist combines teaching with the promotion of self-care. It is likely premature to label the client as noncompliant, and showing him the expected outcomes on his clinical pathway is unlikely to motivate him if he is reluctant. It is appropriate for the nurse to educate and encourage the client rather than simply accepting his refusal and providing no other interventions.

An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first? A) The client's airway should be assessed. B) The nurse should determine the reason for admission. C) The nurse should review the client's medications. D) The client's past medical history is assessed.

Ans: A Feedback: Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priority. Often, the client's difficulty involves airway, breathing, and circulatory problems.

The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next? A) Clarify discrepancies of assessment data with the client. B) Validate client data with members of the health care team. C) Document all data collected in the nursing history and physical examination. D) Seek input from family members regarding the client's breathing at home.

Ans: A Feedback: First, the nurse needs to validate the data with the client, who is the primary source. The nurse can validate data with the health care provider but consulting with the client is the best option. The client must give permission for family members to participate in the health history. Ultimately, the nurse documents all assessment data, both from the history and the physical exam.

8. A nurse instructor explains the concept of health to her students. Which of the following statements accurately describes this state of being? A) Health is a state of optimal functioning. B) Health is an absence of illness. C) Health is always an objective state. D) Health is not determined by the patient.

Ans: A Feedback: Health is a state of optimal functioning or well-being. As defined by the World Health Organization, one's health includes physical, social, and mental components and is not merely the absence of disease or infirmity. Health is often a subjective state; a person may be medically diagnosed with an illness but still consider himself or herself healthy.

36. The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which of the following clinical situations? A) When communicating a client's change in condition to the client's physician B) When providing a change-of-shift report to a colleague C) When documenting the care that was provided to a client whose condition recently deteriorated D) When reporting to a client's family member or significant other

Ans: A Feedback: ISBARR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. ISBARR is considered a framework for communication rather than a format for documentation.

After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis? A) Impaired urinary elimination B) Readiness for enhanced sleep C) Risk for infection D) Possible impaired adjustment

Ans: A Feedback: Impaired urinary elimination is an actual nursing diagnosis because it describes a human response to a health problem that is being manifested. Readiness for enhanced sleep is a wellness diagnosis. Risk for infection is a risk diagnosis, and possible impaired adjustment is a possible nursing diagnosis.

8. What is the unique focus of nursing implementation? A) Client response to health and illness B) Client response to nursing diagnosis C) Client compliance with treatment regimen D) Client interview and physical assessment

Ans: A Feedback: In all nurse-client interactions, the nurse is concerned with the client's response to health and illness and the nurse's ability to meet basic human needs. Whereas other health care professionals focus on selected aspects of the client's treatment regimen, nurses are concerned with how the client is responding to the plan of care in general.

A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information? A) Client'swife B) Medical documents C) Test results D) Assessment data

Ans: A Feedback: In this case, the primary source of information is the client's wife, as she can provide a detailed description of the incident as well as provide the medical history of the client. The medical files, test results, and assessment data are secondary sources of information.

3. The American Nurses Association recommends adherence to defined principles when delegating care tasks to unlicensed assistive personnel. According to these principles, who is responsible and accountable for nursing practice? A) The registered nurse B) The American Nurses Association C) The nurse manager D) The unit's medical director

Ans: A Feedback: It is the registered nurse who is responsible and accountable for nursing practice.

A client with a new colostomy often becomes short and sarcastic when nurses attempt to teach him about the management of his new appliance. The nurse has consequently documented "Noncompliance related hostility" on the client's chart. What mistake has the nurse made when choosing and documenting this nursing diagnosis? A) Presuming to know the factors contributing to the problem B) Identifying a problem that cannot be changed C) Identifying a problem without corroborating evidence in the statement D) Neglecting to identify potential complications related to the problem

Ans: A Feedback: Multiple factors may underlie the client's response to education in a complex and emotionally charged situation, such as receiving a new ostomy. As a result, it is likely presumptuous to ascribe the client's response to hostility. The problem is likely modifiable with a correct approach; the evidence underlying a nursing diagnosis is not normally explicit in the statement itself. The existence of potential complications is not central to the psychosocial nature of this client's situation.

30. A nurse receives an x-ray report on a newly admitted patient suspected of having a fractured tibia. The nurse contacts the physician to report the findings. What role is the nurse engaged in? A) Communicator B) Advocate C) Caregiver D) Researcher

Ans: A Feedback: Nurses are communicators when they report findings to the health care team. Advocacy involves actions such as protecting the patient's safety or rights. Administering care measures directly to the patient demonstrates the caregiver role. Research involves collecting and analyzing data.

2. A graduate nurse recently attended a conference on acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information she learned at the conference. Which nursing variable is the nurse utilizing in the development of the plan of care? A) Research findings B) Resources C) Current standards of care D) Ethical and legal guides to practice

Ans: A Feedback: Nurses concerned about improving the quality of nursing care use research findings to enhance their nursing practice. Reading professional journals and attending continuing education workshops and conferences are excellent ways to learn about new nursing strategies that have proved effective.

4. An older adult client is receiving care on a rehabilitative medicine unit during her recovery from a stroke. She complains that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration? A) Facilitate communication between the different professionals and attempt to coordinate care. B) Educate the client about the unique scope and focus of each member of the healthvcare team. C) Modify the client's plan of care to better reflect the commonalities between the different disciplines. D) Arrange for each professional to perform bedside assessments and interventions simultaneously rather than individually.

Ans: A Feedback: Nurses play a pivotal role in the coordination of care and often need to facilitate communication between members of different disciplines. Educating the client about the role of each professional may be useful, but it does not achieve coordination of care. Similarly, amending the client's plan of care will not create unity and collaboration. It is unrealistic to expect each member of the care team to always visit simultaneously.

31. The client's plan of care is created by the nurse using which guideline for nursing practice? A) Nursing process B) Nursing's Social Policy Statement C) Nurse practice act D) ANA Standards of Nursing Practice

Ans: A Feedback: Nursing process is used by nurses to identify the client's strengths, limitations, and health care needs; to formulate a plan of care to address the health care needs; to plan and implement a plan of care to meet those health care needs; and to evaluate the effectiveness of the plan to achieve established outcomes. The ANA Standards of Nursing Practice defines the activities of nurses that are specific and unique to nursing. Nurse practice acts are laws established by each state to regulate the practice of nursing. Nursing's Social Policy Statement describes the values and social responsibility of nursing, provides a definition and scope of practice for nursing and nursing's knowledge base, including the methods by which nursing is regulated.

After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data? A) Auscultation of the lungs B) Complaint of nausea C) Sensation of burning in her epigastric area D) Belief that demons are in her stomach

Ans: A Feedback: Objective data include techniques of inspection, palpation, percussion, and auscultation. Symptoms, values, perceptions, feelings, beliefs, attitudes, and sensations are sources of subjective data.

The nurse observes the client as he walks into the room. What information will this provide the nurse? A) Information regarding the client's gait B) Information regarding the client's personality C) Information regarding the client's psychosocial status D) Information on the rate of recovery from surgery

Ans: A Feedback: Observation includes looking, watching, examining, scrutinizing, surveying, scanning, and appraising.

16. A nurse is assigned the care of a client who has been admitted to the health care facility with high fever. Which nursing skill should be put into practice at the first contact with the client? A) Assessment B) Caring C) Comforting D) Counseling

Ans: A Feedback: On admission of the client to a health care facility, the nurse would be required to conduct an initial assessment of the client. Therefore, the nurse would implement his or her nursing skills in this case. This can be done by interviewing, observing, and examining the client. Caring skills are put into practice once the nursing needs are determined. Comforting and counseling skills may not have a major role in assessing client problems.

A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he "can't live with this fear." Which of the following diagnoses for this client is correctly written? A) Post-trauma syndrome related to being attacked B) Psychological overreaction related to being attacked C) Needs assistance coping with attack D) Mental distress related to being attacked

Ans: A Feedback: Post-trauma syndrome is a NANDA-approved problem statement and being attacked is the correct etiology. Overreaction and mental distress implies a value judgment by the nurse. Needs assistance addresses the need of the client.

7. A female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside where staff and other clients can hear her. The nurse should respond by modifying which of the following resources? A) Environment B) Personnel C) Equipment D) Patient and visitors

Ans: A Feedback: Providing an environment for the client that is more conducive to privacy and, ultimately, to her elimination needs is necessary in this case. The equipment itself (i.e., the commode) is not the problem, but rather its proximity to others. The staff and the client herself are not central to the client's new problem.

Which of the following reflects the diagnosis phase? A) The nurse identifies that the client does not tolerate activity. B) The nurse performs wound care using sterile technique. C) The nurse sets a tolerable pain rating with the client. D) The nurse documents the client's response to pain medication.

Ans: A Feedback: Recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as activity intolerance, is the focus of diagnosing. Performing wound care is an example of implementation. Setting a tolerable pain rating with the client is an example of planning. Documenting the client's response to pain medication is an example of evaluation.

6. Many of the homeless clients who are supposed to receive care for HIV/AIDS miss their appointments at a clinic because it is located in a high-rise building on a university campus. Several of the clients state that the clinic is difficult to find and in an intimidating environment. This demonstrates that which of the following variables influencing outcome achievement is being inadequately addressed? A) Psychosocial background of clients B) Developmental stage of clients C) Ethical and legal considerations D) Resources

Ans: A Feedback: Requiring clients to attend a clinic that is difficult to access, and located in a daunting environment, shows a lack of consideration for clients' psychosocial backgrounds. Resources, development, and ethics are not central to this lapse in care.

The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who has been admitted to the hospital for treatment of an eating disorder. These risk diagnoses indicate which of the following? A) The client is more vulnerable to certain problems than other individuals would be. B) The diagnoses present significant risks for the development of medical diagnoses. C) The data necessary to make a definitive nursing diagnosis is absent. D) The diagnosis has yet to be confirmed by another practitioner.

Ans: A Feedback: Risk nursing diagnoses are clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation. They do not denote a particular link to medical diagnoses nor do they require independent confirmation. Missing data is associated with possible nursing diagnoses.

The nurse is performing an assessment of a client who has a small wound on the knee, collecting cues about the client's health status. Which of the following would the nurse identify as a subjective cue? A) Sharp pain in the knee B) Small bloody drainage on dressing C) Temperature of 102 degrees F D) Pulse rate of 90 beats per minute

Ans: A Feedback: Sharp pain in the knee is an example of a subjective cue. Subjective cues are imperceptible, immeasurable, and abstract. Small bloody drainage on dressing, a temperature of 102 degrees F, and a pulse rate of 90 beats per minute are examples of objective cues.

A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future? A) The nurse should practice interviewing strategies. B) The nurse should modify data collection tool. C) The nurse should determine specific purpose of data collection. D) The nurse should update the database.

Ans: A Feedback: Strong interviewing skills are needed to obtain the necessary patient data. A common cause of data omission is the nurse's failure to know what information is wanted or not following up on client cues. The nurse only needs to modify the data collection tool if the database is inappropriately organized. If irrelevant or duplicate data is collected, the nurse should determine specific purpose of data collection. Data collection should be ongoing. If the nurse notices that data collection stopped after the initial assessment data were collected, the nurse should update the database.

When documenting subjective data, the nurse should do which of the following? A) Use the client's own words placed in quotation marks. B) Paraphrase the information stated by the client. C) Validate the information with the client's family prior to documentation. D) Record the information using nonspecific words.

Ans: A Feedback: Subjective data should be recorded using the client's own words, whenever possible. Quotation marks should be used around the client's statement. The tendency to use nonspecific terms that are subject to individual definition or interpretation should be avoided.

19. A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention? A) Sitting with the client to encourage her to talk B) Telling the laboratory technician to speed up the results C) Calling the physician for an order for an anxiolytic D) Educating the client about reducing risk factors

Ans: A Feedback: Supportive interventions include recognizing the need for encouragement, unconditional acceptance of behaviors, and the positive effects of being present for clients during stress or crisis. To support the anxious client, the nurse should sit with her and encourage her to talk. Telling the laboratory technician to speed up the results, or calling the physician and taking orders for anxiolytics are inappropriate supportive interventions. Educating the client about reducing risk factors is an educational intervention.

3. Which of the following organizations is the best source of information when a nurse wishes to determine whether an action is within the scope of nursing practice? A) American Nurses Association (ANA) B) American Association of Colleges in Nursing (AACN) C) National League for Nursing (NLN) D) International Council of Nurses (ICN)

Ans: A Feedback: The ANA produces the 2003 Nursing: Scope and Standards of Practice, which defines the activities specific and unique to nursing. The AACN addresses educational standards, while the NLN promotes and fosters various aspects of nursing. The ICN provides a venue for national nursing organizations to collaborate, but does not define standards and scope of practice.

22. A student has completed a nursing program accredited by the Commission on Collegiate Nursing Education. Which of the following is true about the organization? A) It fosters continued improvement in nursing education programs. B) Accreditation is by governmental peer review process. C) It ensures the quality and integrity of diploma nursing programs. D) It uses state-recognized standards to evaluate the programs.

Ans: A Feedback: The Commission on Collegiate Nursing Education fosters continued improvement in nursing education programs. Accreditation is by nongovernmental, peer review process. It ensures the quality and integrity of baccalaureate and graduate nursing programs, not diploma nursing programs. It uses nationally-recognized, not state-recognized, standards to evaluate the programs.

19. A nurse at a health care facility provides information, assistance, and encouragement to clients during the various phases of nursing care. In which of the following activities does the nurse use counseling skills? A) Educating a group of young girls about AIDS B) Telling a client to localize the pain in his abdomen C) Encouraging a client to walk without support D) Assisting a lactating mother in feeding her child

Ans: A Feedback: The activity of educating a group of young girls about AIDS is based on the nurse using counseling skills. Telling a client to localize his pain is an assessment skill. Encouraging a client to walk without support can be both a comforting skill and a caring skill. Assisting a lactating mother in feeding her baby is an example of a caring skill.

32. The nurse is administering immunizations to a group of teens in a county health clinic. The nurse correctly identifies this action as: A) Illness prevention B) Restorative care C) Treatment of disease D) Supportive nursing care

Ans: A Feedback: The aim of illness prevention activities is to reduce the risk for illness, to promote good health habits, and to maintain optimal functioning. Immunization administration is an example of illness prevention. Assisting with crutch walking, and teaching medication administration would be examples of health restoration activities. Administering antibiotics to a patient to treat an infection would be an example of treatment of disease. Hospice care is an example of supportive care.

In planning the care for a client who has pneumonia, the nurse collects data and develops nursing diagnoses. Which of the following is an example of a properly developed nursing diagnosis? A) Ineffective airway clearance as evidenced by inability to clear secretions B) Ineffective health maintenance as evidenced by unhealthy habits C) Ineffective breathing pattern related to pneumonia D) Ineffective therapeutic regimen management due to smoking

Ans: A Feedback: The appropriately written nursing diagnosis is "ineffective airway clearance related to inability to clear secretions." "Ineffective health maintenance related to unhealthy habits" is incorrect because it shows value judgments by the nurse. "Ineffective breathing pattern related to pneumonia" is incorrectly written because it includes a medical diagnosis. "Ineffective therapeutic regimen management due to smoking" is incorrect because the clause "due to" implies a direct cause-and-effect relationship.

35- Organize these events in chronological order, beginning with the earliest (1) and ending with the most recent (5). 1) During the Crusades, religious orders provided nursing care to the sick. 2) Florence Nightingale administered care to British soldiers during the Crimean War. 3) Clara Barton organized the American Red Cross. 4) Mary Elizabeth Mahoney graduated from the New England Hospital for Women and Children in 1879 as America's first African American nurse. 5) Margaret Sanger advocated for contraception and family planning in the United States. A) 1, 2, 3, 4, 5 B) 1, 2, 4, 3, 5 C) 1, 2, 4, 5, 3 D) 1, 2, 3, 5, 4 E) 2, 1, 4, 3, 5

Ans: A Feedback: The correct order of these events is (1) during the Crusades, religious orders provided nursing care to the sick; (2) Florence Nightingale administered care to British soldiers during the Crimean War; (3) Clara Barton organized the American Red Cross; (4) Mary Elizabeth Mahoney graduated from the New England Hospital for Women and Children in 1879 as America's first African American nurse; and (5) Margaret Sanger advocated for contraception and family planning in the United States.

In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is "presence of large scar over left side of face"? A) Etiology B) Problem C) Defining characteristics D) Client need

Ans: A Feedback: The etiology identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. The etiology directs nursing interventions.

A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation? A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward. B) Encourage the novice nurse to develop his or her own tool for data collection. C) Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation. D) Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.

Ans: A Feedback: The novice nurse can improve interpretation skills by independently observing the same situation with a peer, comparing notes afterward, and role-playing various validation techniques.

After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. For what are the nursing diagnoses used? A) Selecting nursing interventions to meet expected outcomes B) Establishing a database of information for future comparison C) Mutually establishing desired outcomes of the plan of care D) Evaluating the effectiveness of the established plan of care

Ans: A Feedback: The nurse formulates, validates, and lists nursing diagnoses for each client. Nursing diagnoses provide the basis for selecting nursing interventions that will achieve valued client outcomes for which the nurse is responsible.

The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using? A) Human Needs (Maslow) model B) Functional Health Patterns model C) Human Response Patterns model D) Body System model

Ans: A Feedback: The nurse is following the Human Needs model based on Maslow's Hierarchy of Human Needs. The Functional Health Patterns model was developed by Gordon and is a framework that identifies 11 functional health patterns and organizes data according to these patterns. The Body System model is often used by the medical community, and it organizes data according to organ and tissue function in various body systems. The Human Response Pattern model focuses on a unitary person.

A nurse completes a health history and physical assessment for an adolescent before he begins football practice. Based on findings, the nurse recommends reinforcing good health habits. What conclusion did the nurse reach after interpreting and analyzing the data? A) No problem B) Possible problem C) Actual problem D) Clinical problem

Ans: A Feedback: The nurse reaches one of four basic conclusions after interpreting and analyzing the client data. Different nursing responses are possible for each conclusion. In this case, the nurse would most likely conclude there was no problem and reinforce the client's health habits.

2. What guidelines do nurses follow to identify the patient's health care needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes? A) Nursing process B) ANA Standards of Professional Performance C) Evidence-based practice guidelines D) Nurse Practice Acts

Ans: A Feedback: The nursing process is one of the major guidelines for nursing practice. Nurses implement their roles through the nursing process. The nursing process is used by the nurse to identify the patient's health care needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes.

34. Each time a nurse administers an insulin injection to a client with diabetes, she tells the client what she is doing and demonstrates each step of preparing and giving the injection. What is the nurse promoting in the client? A) Self-care B) Dependence C) Competence D) Discipline

Ans: A Feedback: The plan of nursing care should include specific instructions for education/learning needs of the client to promote self-care and independence. Competency pertains to the nurse's ability (knowledge, skills, and attitudes) to provide safe and effective care. The nurse's role includes education, counseling, and advocating, but not providing discipline to clients.

25. The nurse is caring for a client with a diagnosis of end-stage renal disease. The client has expressed the desire to be kept comfortable and to not continue further treatment. The daughter arrives from out of town and is demanding to have further testing done to determine the best treatment option for the client. What is the best action for the nurse to take at this time? A) Explain to the daughter the wishes of the client. B) Arrange a meeting between the physician and daughter. C) Contact the imaging center to schedule the testing. D) Persuade the client to agree to the daughter's request.

Ans: A Feedback: The priority is for the nurse to explain to the daughter the wishes of the client and support the client's decision. As an advocate, the nurse implements actions to protect the rights of the client. The other options do not support the client's decision.

A nurse writes the following nursing diagnosis for a client with Alzheimer's disease: Disturbed Thought Processes related to Alzheimer's disease as evidenced by incoherent language. Which part of this diagnosis is considered the problem statement? A) disturbed thought processes B) related to C) Alzheimer's disease D) incoherent language

Ans: A Feedback: The purpose of the problem statement is to describe the health state or health problem of the client as clearly and concisely as possible. Because this section of the nursing diagnosis identifies what is unhealthy about the client and what the client would like to change in his or her health status, it suggests client outcomes. NANDA recommends the use of quantifiers or descriptors to limit or specify the meaning of a problem statement. Disturbed thought processes is a NANDA-approved descriptor for this client problem. The etiology identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor, and in this case is Alzheimer's disease. Incoherent language is considered a defining characteristic or subjective/objective data signaling the existence of an actual or potential health problem.

A nurse who is caring for an unresponsive client formulates the nursing diagnosis, "Risk for Aspiration related to reduced level of consciousness." The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis? A) Is written as a two-part statement B) Describes human response to a health problem C) Describes potential for enhancement to a higher state D) Made when not enough evidence supports the problem

Ans: A Feedback: The risk diagnoses are written as two-part statements because they do not include defining characteristics. An actual nursing diagnosis describes human response to a health problem. Wellness diagnoses describe potential for enhancement to a higher state. A possible nursing diagnosis is made when not enough evidence supports the problem.

A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status? A) To identify a life-threatening problem B) To establish a database for medical care C) To practice respiratory assessment skills D) To facilitate the resident's ability to breathe

Ans: A Feedback: When a life-threatening physiologic or psychological crisis occurs, the nurse performs an emergency assessment to identify life-threatening problems. Emergency assessments are not used to establish a database for medical care, practice assessment skills, or help a physiologic process (such as breathing).

28. The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? A) Notify me right away if the client's systolic blood pressure is 170 or greater. B) Let me know if the client's blood pressure becomes elevated. C) If the client's blood pressure falls outside normal limits, come get me. D) I need to know if the client's blood pressure changes from his normal baseline.

Ans: A Feedback: When delegating tasks, it is essential for the nurse to give clear instructions to the person to whom the task is being delegated. The statement, which includes specific parameters for the systolic blood pressure, clearly identifies what the UAP should be alerted to and the subsequent action to take. The other three options are vague and do not provide adequate direction for the UAP.

Which activity is a possible solution for inadequate nursing staffing? A) Identify the kind and amount of nursing services required. B) Learn to give quality care during designated work period. C) Use a team conference to develop a consistent plan of care. D) Educate the client to become an assertive health care consumer.

Ans: A Feedback: A possible solution for inadequate staffing is to identify the kind and amount of nursing services required. Using a team conference to develop a consistent plan of care is a possible solution for the client who refused to cooperate with the therapeutic regimen. Educating the client to become an assertive health care consumer is a possible solution for the client who quietly accepts whatever care is delivered or not delivered. A possible solution for the nurse who is a candidate for burnout is to learn to give quality care during the designated work period.

The nurse is preparing to mail a client satisfaction questionnaire to a client who was discharged from the hospital four days ago. Which type of evaluation is the nurse conducting? A) Retrospective evaluation B) Peer review C) Nursing audit D) Concurrent evaluation

Ans: A Feedback: A retrospective audit uses post-discharge questionnaires to collect data. A nursing audit is a method of evaluating nursing care that involves reviewing client records to assess the outcomes of nursing care (or the process by which these outcomes were achieved). Concurrent evaluation involves direct observations of nursing care, client interviews, and chart review to determine whether the specified evaluative criteria are met. Peer review involves the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. This is done for the purpose of professional performance improvement.

The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? A) Vulnerability to legal liability since nurse's safe, routine care is not recorded B) Increased workload for nurses in order to complete necessary documentation C) Failure to identify and record client problems and associated interventions D) Significant differences in the charting between nurses due to lack of standardization

Ans: A Feedback: A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing? A) Data, information, knowledge B) Process, documentation, analysis C) Research, controls, variables D) Hypothesis, nursing, practice

Ans: A Feedback: According to the ANA Scope and Standards of Nursing Informatics Practice, nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support clients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology (ANA, 2001, p. vii).

The nurse witnessed a more senior nurse make six unsuccessful attempts at starting an intravenous (IV) line on a client. The senior nurse persisted, stating, "I refuse to admit defeat." This resulted in unnecessary pain for the client. How should the first nurse best respond to this colleague's incompetent practice? A) Report the nurse's practice and have the nurse manager address the matter. B) Encourage the nurse to attend an in-service on IV starts. C) Reassure the nurse that this is a difficult skill and give her feedback on her performance. D) Document an unmet outcome in the client's plan of care.

Ans: A Feedback: According to the study Silence Kills: The Seven Crucial Conversations for Healthcare (Maxfield, Grenny, Patterson, McMillan, & Switzler, 2005), an appropriate response to incompetence is to report the matter and enlist the manager to conduct follow-up. Reassuring the nurse and encouraging education are not sufficient responses to incompetence. This action does not constitute an unmet outcome on the part of the client.

A nurse in a community health center has been having regular meetings with a woman who wants to stop smoking. Which of the following outcome decision options would the nurse document if the woman has not smoked for three months? A) Outcome met B) Outcome partially met C) Outcome not met D) Outcome inappropriate

Ans: A Feedback: After data have been collected and interpreted to determine client outcome achievement, the nurse makes and documents a judgment summarizing the findings. The three decision options are met, partially met, and not met. In this case, the nurse's judgment is that the client has met the expected outcome of smoking cessation.

Ch 19 A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as ... A) Avelox (moxifloxacin) 400 mg daily B) Avelox (moxifloxacin) 400 mg Q.D. C) Avelox (moxifloxacin) 400 mg qd D) Avelox (moxifloxacin) 400 mg OD

Ans: A Feedback: Among the JCAHO's list of "do not use" abbreviations are Q.D., qd, and OD when denoting a once-per-day drug administration. Because of the potential for misinterpretation and consequent drug errors, the JCAHO recommends writing "daily" in the order.

The client reports participating in water aerobics for 60 minutes three times each week. This is an example of what type of outcome? A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome

Ans: A Feedback: An affective outcome involves changes in the client's values, beliefs, and attitude, such as participating in water aerobics. Cognitive outcomes demonstrate increases in client knowledge. Physiologic outcomes are physical changes in the client. Psychomotor outcomes describe the client's achievement of new skills.

Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 feet without the use of mobility aids by 12/12/2011." Several nurses have evaluated the client's progression towards this outcome at various points during her care. Which of the following evaluative statements is most appropriate? A) "12/12/2011 - Outcome partially met. Patient ambulated 75 feet without the use of mobility aids" B) "12/12/2011 - Outcome unmet. Patient's ambulation remains inadequate." C) "12/10/2011 Outcome met, but with the use of a quad cane to assist ambulation." D) "12/14/2011 Outcome met."

Ans: A Feedback: An evaluative statement should include both the decision about how well the outcome was met along with data that support this decision. Characterizing the client's ambulation as "inadequate" is not sufficiently precise. Stating that this outcome was met with the use of a cane contradicts the original terms of the outcome.

What is the primary purpose of an incident report? A) Means of identifying risks B) Basis for staff evaluation C) Basis for disciplinary action D) Format for audiotaped report

Ans: A Feedback: An incident report, also termed a variance or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a client, employee, or visitor. Incident reports should not be used for disciplinary action against staff members.

The nurse is giving a shift report to the oncoming nurse who will be caring for a client with a portacath access device. The oncoming nurse states, I have never taken care of a client with a portacath. Would you give me the basics, so I know what to do? Which standard for establishing and sustaining healthy work environments is the oncoming nurse breaching? A) Appropriate staffing B) Effective decision making C) True collaboration D) Skilled communication

Ans: A Feedback: Appropriate staffing ensures that client needs are effectively matched with nurse competencies. In this scenario, the nurse is ill-prepared to care for the client. The nurse needs structured training to learn about the nursing care of portacaths. Skilled communication requires health team members to communicate in a respectful, non-intimidating manner with colleagues. True collaboration involves skilled communication, mutual respect, shared responsibility, and decision making among nurses, and between nurses and other health team members. Effective decision making ensures nurses are valued and active partners in making policy, directing and evaluating clinical care, and leading organizational operations.

A nurse is interested in improving client care on the unit through performance improvement. What is the first step in this process? A) Discover the problem. B) Plan a strategy. C) Implement a change. D) Assess the change.

Ans: A Feedback: Each nurse must decide how to respond when he or she perceives that client care is being compromised. The four steps listed are all components of the process of performance improvement, with discovering the problem being the first step.

The manager of a medical unit regularly reviews the incident reports that result from errors and near misses that occur on the unit. How should the manager best respond to these incident reports? A) Use them to inform improvements and education on the unit. B) Use them to identify deficient workers for removal or demotion. C) Cross-reference them with client satisfaction reports from the unit. D) Use them to identify individuals who would benefit from probationary measures.

Ans: A Feedback: It is most beneficial for the manager to frame incident reports as sources of improvement, which can improve both client care and the work environment. Punitive follow-up by demotion, probation, or removal is likely to create reluctance among staff to complete incident reports. Cross-referencing incident reports with client satisfaction reports is unlikely to result in substantial improvements to the unit's care and culture.

An older adult client has lost significant muscle mass during her recovery from a systemic infection. As a result, she has not yet met the outcomes for mobility and activities of daily living that are specified in her nursing plan of care. How should her nurses best respond to this situation? A) Continue the plan of care with the aim of helping the client achieve the outcomes. B) Terminate the plan of care since it does not accurately reflect the client's abilities. C) Modify the plan of care to better reflect the client's current functional ability. D) Replace the client's individualized plan of care with a clinical pathway.

Ans: A Feedback: Nurses regularly evaluate clients' progression toward the achievement of outcomes that are specified in plans of care. When clients need more time to achieve desired outcomes, it is appropriate to continue with the existing plan of care. It is not necessary to terminate the plan of care and modification may be premature. Abandoning the plan and replacing it with a clinical pathway is counterproductive to the continuity of care.

The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? A) Narrative notes B) SOAP notes C) Focus charting D) Charting by exception

Ans: A Feedback: One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

Nursing care and client outcomes may be evaluated by use of a retrospective evaluation process. Which of the following is an example of a retrospective evaluation process? A) Postdischarge questionnaire. B) Direct observation of nursing care. C) Client interview during hospitalization. D) Review of client's chart during hospitalization.

Ans: A Feedback: Retrospective evaluation may use postdischarge questionnaires and client interviews, or chart reviews after the client has been discharged. Concurrent evaluation occurs while the client is receiving care and may include the following: direct observation of nursing care and client interviews; and direct observation of chart reviews during hospitalization.

A nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation? A) Information is documented in separate forms by each health care personnel. B) It is a unified, cooperative approach for resolving the client's problems. C) It is organized at one location according to the client's health problems. D) It is compiled to facilitate communication among health care professionals.

Ans: A Feedback: Source-oriented documentation is a record organized according to the source of documented information. This type of record contains separate forms on which health care personnel make written entries about their own specific activities in relation to the client's care. The problem-oriented method of recording demonstrates a unified, cooperative approach to resolving the client's problems. Source-oriented records are organized at numerous locations; there is not one location for information. The problem-oriented record is compiled to facilitate communication among health care professionals.

A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality? A) Writing the client's name on the student care plan B) Providing the instructor with plans for care C) Discussing the medications with a unit nurse D) Providing information to the physician about laboratory data

Ans: A Feedback: Students using client records are bound professionally and ethically to keep in strict confidence all the information they learn from those records. The student may discuss care with the instructor, medications with a staff nurse, and laboratory data with the physician. The student should not use actual client names or other identifiers in written assignments or oral reports.

The nurse has responded to a client's request to view her medical chart by arranging a meeting between the client, the clinical nurse leader, and her primary care physician. The nurse is exemplifying which of the following characteristics of quality health care? A) Information B) Science C) Cooperation D) Individualization

Ans: A Feedback: The Institute of Medicine's Committee on Quality Health Care in America has identified aspects of care that clients can reasonably expect. One of these expectations is information, which is manifested by allowing clients access to their medical records. Other characteristics that clients can expect are knowledge-based care (science), coordination between professionals (cooperation), and respect for client choices and preferences (individualization).

Which one of the following methods of documentation is organized around client diagnoses rather than around patient information? A) Problem-oriented medical record (POMR) B) Source-oriented record C) PIE charting system D) focus charting

Ans: A Feedback: The POMR is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care.

A nurse organizes client data using the SOAP format. Which of the following would be recorded under "S" of this acronym? A) Client complaints of pain B) Client history C) Client's chief complaint D) Client interventions

Ans: A Feedback: The SOAP format (subjective data, objective data, Assessment [the caregiver's judgment about the situation], plan) is used to organize data entries in the progress notes of the POMR. A client complaint of pain is subjective data (S).

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? A) "Client complaining of abdominal pain rated at 8/10." B) "Client is guarding her abdomen and occasionally moaning." C) "Client has a history of recent abdominal pain." D) "2 mg Dilaudid PO administered with good effect"

Ans: A Feedback: The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a complaint of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

The correct sequence of steps for performance improvement is: 1. Discover a problem. 2. Plan a strategy using indicators. 3. Implement a change. 4. Assess the change. A) 1, 2, 3, 4 B) 1, 4, 2, 3 C) 4, 1, 2, 3 D) 1, 2, 4, 3 E) 1, 3, 2, 4

Ans: A Feedback: The correct sequence of steps for performance improvement is (1) discover a problem; (2) plan a strategy using indicators; (3) implement a change; and (4) assess the change; if the change is not met, plan a new strategy.

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which of the following? A) The physician's assessment and treatment B) Results of laboratory and diagnostic studies C) Nursing documentation and plan of care D) Information from other members of the health care team

Ans: A Feedback: The medical history, physical examination, and progress notes record the findings of physicians as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment.

A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which of the following actions should the nurse perform before revising a plan of care? A) Discuss any lack of progress with the client. B) Collect information on abnormal functions. C) Identify the client's health-related problems. D) Select appropriate nursing interventions.

Ans: A Feedback: The nurse should discuss any lack of progress with the client so that both the client and the nurse can speculate on what activities need to be discontinued, added, or changed. Collecting information on abnormal functions and risk factors is done during the assessment. Identification of the client's health-related problems is done during diagnosis. Nurses select appropriate nursing interventions and document the plan of care in the planning stage of the nursing process, not during evaluation.

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the health care provider? A) ISBAR B) EMAR C) SOAP D) CBE

Ans: A Feedback: The nurse should use ISBAR to communicate verbally to the health care provider. Identify/Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) is the communication tool to provide critical client information to the health care provider. EMAR is Electronic Medication Administration Record, which documents medication administration. SOAP is Subjective, Objective, Assessment, and Plan, which is a progress note that relates to only one health problem. CBE is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution.

Ch 18 Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will do what? A) Terminate the plan of care. B) Modify the plan of care. C) Continue the plan of care. D) Re-evaluate the plan of care.

Ans: A Feedback: The nurse will terminate the plan of care when each expected outcome has been achieved. Modifying the plan of care is necessary if there are difficulties in achieving the outcomes. Re-evaluating each step of the nursing process is a step in the modification of a plan of care. Continuing the plan of care occurs if more time is needed to achieve the outcomes.

Which of the following examples of client data needs to be validated? Select all that apply. A) A client has trouble reading an informed consent, but states he does not need glasses. B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall. C) A nurse examining a client with a respiratory infection documents fever and chills. D) A client in a nursing home states that she is unable to eat the food being served. E) A pregnant client is experiencing contractions that are two minutes apart.

Ans: A, B Feedback: Because validation of all data is neither possible nor necessary, nurses need to decide which items need verification. For example, data need to be verified when there are discrepancies: A patient tells the nurse he is fine and has no concerns, but the nurse notes that he demonstrates tense body musculature and seems curt in his responses. When there is a discrepancy between what the person is saying and what the nurse is observing, validation is necessary to determine accuracy. Data also need verification when they lack objectivity.

Which client outcome is a physiologic outcome? Select all that apply. A) The client's HA1c is 7.4%. B) The client's blood pressure is 118/74. C) The client rates his or her pain rating as 6. D) The client self-administers insulin subcutaneously. E) The client describes manifestations of wound infection.

Ans: A, B, C Feedback: Physiologic outcomes are physical changes in the client, such as pain ratings and blood pressure and HA1c measurements. Psychomotor outcomes describe the client's achievement of new skills, such as insulin administration. Cognitive outcomes demonstrate gains in client knowledge, such as manifestations of infection.

Which activity does the nurse engage in during evaluation? Select all that apply. A) Collect data to determine whether desired outcomes are met. B) Assess the effectiveness of planned strategies. C) Adjust the time frame to achieve the desired outcomes. D) Involve the client and family in formulating desired outcomes. E) Initiate activities to achieve the desired outcomes.

Ans: A, B, C Feedback: The nurse establishes desired outcomes with the client and family during the outcome identification and planning stage. The nurse initiates activities to achieve the desired outcomes during the implementation stage. During the evaluation stage, the nurse collects data to determine whether desired outcomes are met, assesses the effectiveness of planned strategies, and adjusts the time frame to achieve the desired outcomes.

Nurses apply critical thinking to clinical reasoning and judgment in their nursing practice every day. Which of the following are characteristics of this practice? Select all that apply. A) It is guided by standards, policies and procedures, ethics codes, and laws. B) It is based on principles of nursing process, problem solving, and the scientific method. C) It carefully identifies the key problems, issues, and risks involved. D) It is driven by the nurse's need to document competent, efficient care. E) It calls for strategies that make the most of human potential.

Ans: A, B, C, E Feedback: Critical thinking is guided by standards, policies and procedures, ethics codes, and laws; is based on principles of nursing process, problem-solving, and the scientific method; and carefully identifies the key problems, issues, and risks involved. It is driven by client, family, and community needs, as well as nurses' needs to give competent, efficient care (e.g., streamlining paperwork to free nurses for client care). It calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve.

Which of the following are examples of breaches of client confidentiality? Select all that apply. A) A nurse discusses a client with a coworker in the elevator. B) A nurse shares her computer password with a relative of a client. C) A nurse checks the medical record of a client to see who should be called in an emergency. D) A nurse updates the employer of a client regarding the client's return to work. E) A nurse uses a computer to document a client's response to pain medication.

Ans: A, B, D Feedback: Nurses may use computers to document client data as long as they are not in a public area, and as long as the computer is shut down following the entries. A nurse can also check the medical record for a relative to call in case of an emergency. All the other examples are violations of client confidentiality.

Which of the following is an essential feature of professional nursing? Select all that apply. A) Providing a caring relationship to facilitate health and healing B) Attention to a range of human experiences and responses to health and illness C) Use of objective data to negate the client's subjective experience D) Use of judgment and critical thinking to form a medical diagnosis E) Advancement of professional nursing knowledge through scholarly inquiry

Ans: A, B, E Feedback: As the role has changed, definitions of nursing have evolved to acknowledge the following essential features of professional nursing: (1) providing a caring relationship that facilitates health and healing, (2) attention to the range of human experiences and responses to health and illness within the physical and social environments, (3) integration of objective data with knowledge gained from an appreciation of the client's or group's subjective experience, (4) application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking, (5) advancement of professional nursing knowledge through scholarly inquiry, and (6) influence on social and public policy to promote social justice.

Which of the following statements accurately describes the impact on nursing of using NIC/NOC standardized languages? Select all that apply. A) They demonstrate the impact that nurses have on the system of healthcare delivery. B) They standardize and define the knowledge base for nursing curricula and practice. C) They limit the number of appropriate nursing interventions to be selected. D) They hinder the teaching of clinical decision making to novice nurses. E) They enable researchers to examine the effectiveness and cost of nursing care.

Ans: A, B, E Feedback: Using NIC/NOC standardized language demonstrates the impact that nurses have on the system of health care delivery; standardizes and defines the knowledge base for nursing curricula and practice; facilitates the selection of appropriate nursing interventions; facilitates the teaching of clinical decision making to novice nurses; enables researchers to examine the effectiveness and cost of nursing care; assists educators to develop curricula that better articulate with clinical practice; assists administrators in planning more effectively for staff and equipment needs; promotes the development and use of nursing information systems; and communicates the nature of nursing to the public.

Which of the following are examples of incidental disclosures of client health information that are permitted? Select all that apply. A) A nurse working in a physician's office puts out a sign-in sheet for incoming clients. B) Two nurses are overheard talking about a client through the door of an empty client room. C) A nurse places a client chart in a holder on the examining room door with the name facing out. D) A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms. E) A nurse calls out the name of a client who is seated in the waiting room.

Ans: A, B, E Feedback: Permitted incidental disclosures of PHI include using sign-in sheets without the reason for visit; the possibility of a conversation being overheard if measures are taken to be private; placing a client chart on the door with the face pages facing inward; placing an x-ray on a light board as long as it is not unattended; calling the name of a waiting patient; and leaving appointment reminders on answering machines (provided only a minimal amount of information is given).

Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? Select all that apply. A) U (unit) B) QD (daily) C) NPO (nothing per os) D) mL (milliliters) E) > (greater than)

Ans: A, B, E Feedback: The words "unit", "daily", "greater than" and "less than" should be spelled out. NPO, mL, and mcg are acceptable abbreviations.

In which of the following clients has the order of priorities for nursing diagnoses changed? Select all that apply. A) A client in a long-term care facility who had a stroke B) A client who is recovering from a broken leg C) A client who insists on using the bathroom instead of a bedpan D) A client who appears confused after taking pain medication E) A pregnant client whose contractions are progressing as anticipated

Ans: A, C, D Feedback: The work of setting priorities demands careful critical thinking. When planning nursing care, the nurse should consider the following: Have changes in the client's health status influenced the priority of nursing diagnoses? Have changes in the way the client is responding to health and illness (or the plan of care) affected those nursing diagnoses that can be realistically addressed? Are there relationships among diagnoses that require that one be worked on before another can be resolved? Do several client problems need to be dealt with together.

24. The nurse is trying to determine factors influencing a client who is not following the plan of care. Which client statement identifies a potential factor interfering with following the plan of care? Select all that apply. A) I don't drive so I was unable to fill my prescription. B) I consult the list of low sodium foods when preparing meals. C) My social security check does not come until next week. D) I dropped the strips for my finger-stick blood glucose testing in the bath water. E) "My daughter helps me with my range of motion exercises every morning and afternoon."

Ans: A, C, D Feedback: Common factors that contribute to a client not following the plan of care include inability to afford treatment (social security check) and limited access to treatment (doesn't drive; damaged testing strips).

Which of the following is a correctly written client goal? Select all that apply. A) The client will identify five low-sodium foods by October 9. B) The client will know the signs and symptoms of infection. C) The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. D) The client will understand the side effects of digoxin (Lanoxin). E) The client will eat at least 75% of all meals by May 5.

Ans: A, C, E Feedback: Outcomes are client-centered, use action verbs, identify measurable criteria, and include a time frame as to when the outcome should be achieved. A correctly written outcome will identify who (the client) will do what (eat), how well (75%) under what circumstances (not always included), and by when (May 5). Understand and know are vague and are not action-oriented.

23. Which example reflects client variables that influence outcome achievement? Select all that apply. A) The client was born with cystic fibrosis. B) The nurse works at a hospital in a diverse community. C) Nursing interventions are consistent with standards of care. D) The client is a college graduate and is employed. E) The client engages in activities associated with Ramadan.

Ans: A, D, E Feedback: Important client variables that influence outcome achievement include the physical health of the client, level of education attained, and cultural practices that impact life and health practices. Nurse variables, such as working in a diverse community, and standards of practice also influence client outcome achievement.

Which of the following are examples of common factors in a client that may influence assessment priorities? Select all that apply. A) Diet and exercise program B) Standing in the community C) Ability to pay for services D) Developmental stage E) Need for nursing

Ans: A, D, E Feedback: The purpose for which the assessment is being performed offers the best guideline about what type and how much data to collect. Assessment priorities are influenced by the client's health orientation, developmental stage, culture, and need for nursing. After the comprehensive nursing assessment has been completed, client health problems dictate assessment priorities for future nurse-client interactions.

A nurse working in a hospital setting discovers problems with the delivery of nursing care on the pediatric unit. Which of the following suggestions from the Institute of Medicine's Committee on Quality of Health Care in America (Kohn, Corrigan, & Donaldson, 2000) could help redesign and improve care? Select all that apply. A) Base care on continuous healing relationships. B) Customize care based on available resources. C) Keep the nurse as the source of control. D) Share knowledge and allow for free flow of information. E) Practice evidence-based decision making.

Ans: A, D, E Feedback: The Institute of Medicine's Committee on Quality of Health Care in America (Kohn, Corrigan, & Donaldson, 2000) suggests 10 new rules to redesign and improve care: (1) care based on continuous healing relationships, (2) customization based on client needs and values, (3) the client as the source of control, (4) shared knowledge and the free flow of information, (5) evidence-based decision making, (6) safety as a system property, (7) the need for transparency, (8) anticipation of needs, (9) continuous decrease in waste, and (10) cooperation among clinicians.

Which of the following data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply. A) The client's chemotherapy causes him nausea and loss of appetite. B) The client became teary when his daughter from out of state came to the bedside. C) The client's ileostomy put out 125 mL of effluent in the past four hours. D) The patient is unwilling to manipulate or empty his ostomy bag. E) The patient has been experiencing fatigue in recent weeks.

Ans: A, E Feedback: Reports of nausea, anorexia, and fatigue are subjective data that depend on the client's self-report. Weeping, ostomy output, and an inability to perform a kinesthetic task are observable assessment findings that would be characterized as objective.

Which of the following groups of terms best describes a nurse-initiated intervention? A) Dependent, physician-ordered, recovery B) Autonomous, clinical judgment, client outcomes C) Medical diagnosis, medication administration D) Other health care providers, skill acquisition

Ans: B Feedback: A nursing intervention is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes. Nurse-initiated interventions are autonomous (independently performed).

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a physician-initiated intervention? A) Teach client how to transfer from bed to chair and chair to bed. B) Administer oxygen 4 L/min per nasal cannula. C) Assist the client with coughing and deep breathing every hour. D) Monitor intake and output every 2 hours.

Ans: B Feedback: A physician-initiated intervention is an intervention initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a physician's order. A physician's order is required for the nurse to administer drugs, such as oxygen. A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnosis and expected outcomes. Nursing-initiated interventions, such as teaching client how to transfer, assisting with coughing and deep breathing, and monitoring intake and output do not require a physician's order.

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? A) Evaluate the need for antibiotics. B) Resolve the client's anxiety. C) Provide preoperative education. D) Prepare the client for surgery.

Ans: B Feedback: A priority is something that takes precedence in position, deemed the most important among several items. The client's preparation for surgery is important, but to have a successful outcome, the nurse must address the psychosocial issues related to anxiety.

A nurse is examining a child two years of age. Based on her findings, she initiates a care plan for a potential problem with normal growth and development. Which step of the nursing process identifies actual and potential problems? A) Assessing B) Diagnosing C) Planning D) Implementing

Ans: B Feedback: After assessing the need for nursing care, the nurse clearly identifies client strengths, and actual and potential problems in diagnoses.

A nurse interviews a pregnant teenager and documents her answers on the client record. At the same time, the nurse responds to the client's concerns and makes a referral for counseling and maternity care. This scenario is an example of which of the descriptors of the nursing process? A) Systematic B) Dynamic C) Outcome oriented D) Universally applicable

Ans: B Feedback: Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. No one step in the nursing process is a one-time phenomenon; each step flows into the next step. In some nursing situations, all five stages occur almost simultaneously.

What nursing organization first legitimized the use of the nursing process? A) National League for Nursing B) American Nurses Association C) International Council of Nursing D) State Board of Nursing

Ans: B Feedback: Although the term "nursing process" was first used by Lydia Hall in 1955 and nursing theorists delineated specific steps in a process approach to nursing, use of the nursing process was legitimized in 1973, when the American Nurses Association's Congress for Nursing Practice developed Standards of Practice to guide nursing performance.

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation? A) Continue to follow the written plan of care. B) Make recommendations for revising the plan of care. C) Ask another health care professional to design a plan of care. D) State "goal will be met at a later date."

Ans: B Feedback: Client outcomes are meaningless unless the nurse evaluates the client's progress toward their achievement. If the plan is not achieved (not met), recommendations for revising the plan of care are included in the evaluative statement.

A nurse is discharging a client from the hospital. When should discharge planning be initiated? A) At the time of discharge from an acute healthcare setting B) At the time of admission to an acute health care setting C) Before admission to an acute health care setting D) When the client is at home after acute care

Ans: B Feedback: Discharge planning is best carried out by the nurse who worked most closely with the client and family. In acute care settings, comprehensive discharge planning begins when the client is admitted for treatment.

A home health nurse reviews the nursing care with the client and family and then mutually discusses the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating? A) Diagnosing B) Planning C) Implementing D) Evaluating

Ans: B Feedback: During the planning step, the nurse identifies expected outcomes of the plan of care. The plan of care should be holistic and individualized, specify desired client goals and related outcomes, and identify the nursing interventions most likely to meet those expected outcomes.

Which of the following is not appropriate in writing client-centered measurable outcomes? A) The client or a part of the client B) A flexible time frame C) Observable, measurable terms D) The action the client will perform

Ans: B Feedback: In writing client-centered measurable outcomes, a target time is required. This target time specifies when the client is expected to be able to achieve the outcome. The other options given (the client or part of the client; observable and measurable terms; the action the patient will perform) are all part of client-centered measurable outcomes.

A nurse asks a multidisciplinary team to collaborate in developing the most appropriate plan of care to meet the needs of an adolescent with a severe head injury. Which of the blended skills essential to nursing practice is the nurse using? A) Cognitive skills B) Interpersonal skills C) Technical skills D) Ethical/legal skills

Ans: B Feedback: Interpersonally skilled nurses establish and maintain caring relationships that facilitate the achievement of valued goals, and simultaneously affirm the worth of those in the relationship. They are, among other things, able to work collaboratively with the health care team to reach valued goals.

An experienced ICU nurse is mentoring a student. The nurse tells the student, "I think something is going wrong with your client." What type of clinical decision making is the experienced nurse demonstrating? A) Trial-and-error problem solving B) Intuitive thinking C) Scientific problem solving D) Methodical reasoning

Ans: B Feedback: Nurses today acknowledge the role of intuitive thinking in clinical decision making. Many veteran nurses can describe situations in which an "inner prompting" led to a quick nursing intervention that saved a client's life. However, intuitive problem solving comes with years of practice and observation.

Which of the following is an example of a well-stated nursing intervention? A) Client will drink 100 mL of water every 2 hours while awake. B) Offer client 100 mL of water every 2 hours while awake. C) Offer client water when he complains of thirst. D) Client will continue to increase oral intake when awake.

Ans: B Feedback: Nursing interventions describe in writing the specific nursing care to be implemented for the client. They include information that answers the questions who, what, where, when, and how.

A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have? A) The written outcomes are designed to meet nursing goals B) To encourage the client and family to be involved C) To discourage additions by other healthcare providers D) Why the nurse believes the outcome is important

Ans: B Feedback: One of the most important considerations in writing outcomes is to encourage the client and family to be involved in goal development as their abilities and interest permit. The more involved they are, the greater the probability the goals will be achieved.

Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning? A) "How do I best cluster these data and cues to identify problems?" B) "What problems require my immediate attention or that of the team?" C) "What major defining characteristics are present for a nursing diagnosis?" D) "How do I document care accurately and legally?"

Ans: B Feedback: Questions to facilitate critical thinking during outcome identification and planning include those related to setting priorities, such as "Which problems require my immediate attention or that of the team?" and "Which problems are most important to the client?"

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 what? A) Promoting the nurse's self-esteem. B) Reflective practice. C) Assessment of oneself. D) Learning from mistakes.

Ans: B Feedback: Reflective practice is the use of self-evaluation by nurses committed to quality nursing practice. The others may be additional gains but are not descriptive of self-evaluation.

While developing the plan of care for a new client on the unit the nurse must identify expected outcomes that are appropriate for the new client. What is a resource for identifying these appropriate outcomes? A) Community Specific Outcomes Classification (CSO) B) The Nursing-Sensitive Outcomes Classification (NOC) C) State Specific Nursing Outcomes Classification (SSNOC) D) Department of Health and Human Resources Outcomes Classification (HHROC)

Ans: B Feedback: Resources for identifying appropriate expected outcomes include the Nursing-Sensitive Outcomes Classification (NOC) (Chart 3-6) and standard outcome criteria established by health care agencies for people with specific health problems. The other options are incorrect because they do not exist.

A nurse is caring for a client in the ER who was injured in a snowmobile accident. The nurse documents the following client data: uncontrollable shivering, weakness, pale and cold skin. Th nurse suspects the client is experiencing hypothermia. Upon further assessment, the nurse notes a heart rate of 53 BPM and core internal temperature of 90°F, which confirms the initial diagnosis. The nurse then devises a plan of care and continues to monitor the client to evaluate the outcomes. This nurse is using which of the following types of problem solving in her care of this client? A) Trial-and-error B) Scientific C) Intuitive D) Critical thinking

Ans: B Feedback: Scientific problem solving is a systematic, seven-step, problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in conclusion or revision of the study. This method is used most correctly in a controlled laboratory setting but is closely related to the more general problem-solving processes commonly used by health care professionals as they work with clients, such as the nursing process.

Which of the following client outcomes best describes the parameters for achieving the outcome A) The client will eat a well-balanced diet. B) The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow. C) The client will cleanse his wound with soap and water and apply a dry sterile dressing. D) The client will be without pain in 24 hours.

Ans: B Feedback: The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow possesses all parameters for achieving the outcome.

The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process? A) Planning B) Diagnosis C) Implementation D) Outcome identification

Ans: B Feedback: The diagnosis phase involves the analysis of information and deriving the meaning from the analysis. The planning phase involves preparing a care plan and directing the nursing staff in providing care. The implementation phase involves initiation, evaluation of response to the plan, record of nursing actions, and client response to actions. Outcome identification involves formulating and documenting measurable, realistic, client-focused goals.

A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority? A) The need to have nutrition B) The need to feel good about oneself C) The need to live in a safe environment D) The need for love from others

Ans: B Feedback: When setting priorities, it is best to first meet the needs that the client believes are most important. In this situation, the woman is not refusing food altogether; rather, she wants to feel good about herself (self-esteem) when she does eat.

17. A nurse is caring for a client with a hernia. Which of the following statements should the nurse use while counseling the client about his condition? A) "Open hernioplasty is the best surgery for you." B) "Open and laparoscopic hernioplasty are available." C) "You are not a suitable candidate for hernioplasty." D) "I had a bad experience when I underwent hernioplasty."

Ans: B Feedback: A counselor should provide the client with unbiased information from which to choose. Therefore, the statement that "Open and laparoscopic hernioplasty are available" should be used by the nurse when counseling a client with hernia. The nurse should, however, refrain from giving a personal opinion, so it should not be mentioned which surgery is best for the client; likewise, the nurse should not bring up his or her own past experiences. By reserving personal opinions, a nurse promotes the right of every person to make his or her own decisions and choices on matters affecting health and illness care. Telling the client about his suitability to surgery or the best surgery for him may be biased from the experiences of the past.

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do? A) Initial assessment B) Focused assessment C) Emergency assessment D) Time-lapsed assessment

Ans: B Feedback: A focused assessment is completed by the nurse to gather data about a specific problem that has already been identified. It is also used to identify new or overlooked problems.

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Possible nursing diagnosis D) Wellness diagnosis

Ans: B Feedback: Actual nursing diagnoses represent problems that have been validated by the presence of major defining characteristics. An actual nursing diagnosis has four components: label, definition, defining characteristics, and related factors.

29. A nurse is caring for a young victim of a terrorist attack. During the rehabilitative process, the nurse assists the client in bathing and dressing. What role the nurse is engaged in? A) Advocate B) Caregiver C) Counselor D) Educator

Ans: B Feedback: As providers of care, nurses assume responsibility for helping clients promote, restore, and maintain health and wellness. Communicating the client's needs and concerns, and protecting the client's rights are components of the advocacy role of nursing. The nurse is simply assisting in hygiene measures; no education or counseling is being provided.

5. Which of the following nursing pioneers established the Red Cross in the United States in 1882? A) Florence Nightingale B) Clara Barton C) Dorothea Dix D) Jane Addams

Ans: B Feedback: Clara Barton volunteered to care for wounds and feed union soldiers during the civil war, served as the supervisor of nurses for the Army of the James, organized hospitals and nurses, and established the Red Cross in the United States in 1882.

14. A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The client has visitors in the room. What should the nurse do? A) Ask the visitors to leave the room. B) Ask the client if visitors should remain in the room. C) Tell the client to ask the visitors to leave the room. D) Wait until the visitors leave to begin the procedure.

Ans: B Feedback: If visitors are in the client's room, check with the client to see whether she or he wants the visitors to stay during the procedure.

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? A) Complete B) Focused C) General D) Time-lapse

Ans: B Feedback: In focused assessments, the nurse determines whether the problem still exists and whether the status of the problem has changed.

25. A licensed practice nurse (LPN) is working as a staff nurse. What role do the LPNs working as staff nurses play? A) Work only in long-term care facilities and at client's homes B) Provide direct nursing care to the clients in the health care facility C) Work only as care providers, team members, and communicators D) Supervise the work of charge nurses working in different units

Ans: B Feedback: LPNs working as staff nurses provide direct nursing care to the clients in the health care facility. Staff nurses may work in hospitals, the community, clinics, long-term care facilities, or homes. They work not only as care providers, team members, and communicators but also as decision makers, client advocates, and educators. They do not supervise the work of charge nurses working in different units. Their work is coordinated by the charge nurse or the team leader.

Which of the following client care concerns is clearly a nursing responsibility? A) Prescribing medications B) Monitoring health status changes C) Ordering diagnostic examinations D) Performing surgical procedures

Ans: B Feedback: Monitoring for health status changes is clearly a nursing responsibility. The other options are medical responsibilities, although in some instances an advanced practice nurse practitioner may be responsible for A and C.

What is the nurse accountable for, according to the state nurse practice act? A) Continuing education B) Nursing diagnoses C) Prescribing medications D) Mentoring other nurses

Ans: B Feedback: State nurse practice acts have included diagnosis as part of the domain of nursing practice for which nurses are held accountable.

A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data? A) Blood pressure B) Nausea C) Heart rate D) Respiratory rate

Ans: B Feedback: Subjective data are those which the client can feel and describe. Nausea is subjective data, as it can only be described and not measured. Blood pressure, heart rate, and respiratory rate are measurable factors and are therefore objective data.

9. A nurse incorporates the health promotion guidelines established by the U.S. Department of Health document: Healthy People 2010. Which of the following is a health indicator discussed in this document? A) Cancer B) Obesity C) Diabetes D) Hypertension

Ans: B Feedback: The 10 leading indicators of health established by Healthy People 2010 are: physical activity, excessive weight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunizations, and access to health care.

20. Educating clients on their diabetic regimen of administering insulin is the implementation of which skill? A) Intrinsic B) Technical C) Interpersonal D) Visual

Ans: B Feedback: The administration of insulin is a technical skill. Technical competence means being able to use equipment, machines, and supplies in a particular specialty.

A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? A) Initial assessment B) Focused assessment C) Time-lapsed reassessment D) Emergency assessment

Ans: B Feedback: The nurse is performing a focused assessment to determine whether the problem still exists, and whether the status of the problem has changed. An initial or admission assessment is the initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction. Time-lapsed reassessment is performed after the initial assessment when substantial periods of time have elapsed between assessments. An emergency assessment is performed any time a physiologic, psychological, or emotional crisis occurs.

24. During the clinical rotation, a nurse documents the vital signs of a client on the bedside chart. What role is the nurse playing in such a situation? A) Decision maker B) Communicator C) Coordinator D) Client advocate

Ans: B Feedback: The nurse is providing, in written form, the client's vital signs to the health care provider checking the bedside chart during his or her clinical rounds, so the nurse acts as a communicator. The nurse is not making any decisions here, so the role is not that of a decision maker. The nurse is not playing the role of a coordinator or a client advocate. When the nurse coordinates services offered by a variety of health care professionals, the nurse acts as a coordinator. As a client advocate, the nurse should protect the client, understanding the client's needs and concerns.

A nurse caring for an older adult client in a long-term care facility notices that the bedding is wet when the client gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario? A) No problem B) Possible problem C) Actual problem D) Clinical problem

Ans: B Feedback: The nurse reaches one of four basic conclusions after interpreting and analyzing the client data: no problem, possible problem, actual or potential problem, or clinical problem. When dealing with a possible problem, the nurse must collect more data to confirm or disprove a suspected problem.

A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make? A) Number of rooms in the house B) Safety of the immediate environment C) Frequency of home visits to be made D) Friendliness of the client and family

Ans: B Feedback: The nurse should also observe the safety of the immediate environment. Observation is the conscious and deliberate use of the five senses to gather data. Each time a client is observed, the nurse observes current responses, ability to provide self-care, the immediate environment, and the larger environment.

9. The researchers developing classifications for interventions are also committed to developing a classification of which of the following? A) Diagnoses B) Outcomes C) Goals D) Data clusters

Ans: B Feedback: The researchers involved in the development of NICs are also committed to developing a classification of client outcomes for nursing interventions, called Nursing Outcomes Classifications (NOCs). This research aims to identify, label, validate, and classify nursing-sensitive client outcomes and indicators, evaluate the validity and usefulness of the classification in clinical field-testing, and define and test measurement procedures for the outcomes and indicators.

20. A student wants to join a nursing program that provides flexibility in working at both staff and managerial positions. Which nursing program should the nurse suggest for this student? A) Hospital-based diplomas B) Baccalaureate nursing programs C) Associate degree programs D) Continuing nursing programs

Ans: B Feedback: The student could opt for a baccalaureate nursing program. Baccalaureate-prepared nurses have the greatest flexibility in qualifying for nursing positions at both staff and managerial levels. Hospital-based diploma programs are three-year courses and provide maximum exposure to clinical nursing. Students becoming nurses through the associate degree program would not be expected to work in a management position. Continuing nursing programs are on-the-job educational programs.

Which of the following questions or statements would be an appropriate termination of the health history interview? A) "Well, I can't think of anything else to ask you right now." B) "Can you think of anything else you would like to tell me?" C) "I wish you could have remembered more about your illness." D) "Perhaps we can talk again sometime. Goodbye."

Ans: B Feedback: The successful interview is concluded carefully. After summarizing the data, it is helpful to ask the client if he or she has anything else to tell the nurse. This gives the client the chance to add data the nurse did not think to include.

What is the focus of a diagnostic statement for a collaborative problem? A) The client problem B) The potential complication C) The nursing diagnosis D) The medical diagnosis

Ans: B Feedback: To write a diagnostic statement for a collaborative problem, the nurse should focus on the potential complications of the problem and use "PC" (for potential complication), followed by a colon, and list the complications that might occur. For clarity, the nurse should link the potential complications and the collaborative problem by using "related to."

In what type of documentation method would a nurse document narrative notes in a nursing section? A) Problem-oriented medical record B) Source-oriented record C) PIE charting system D) Focus charting

Ans: B Feedback: A source-oriented record is one in which each health care group keeps data on its own separate form (e.g., physicians, nurses, and laboratory). Progress notes written by nurses using this method are narrative notes.

Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse? A) Problem-oriented medical record B) Charting by exception C) PIE charting system D) Focus charting

Ans: B Feedback: Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes. A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing.

What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation? A) Intuitive thinking B) Critical thinking C) Traditional knowing D) Rote memory

Ans: B Feedback: Each element of evaluation requires the nurse to use critical thinking about how best to evaluate the client's progress toward valued outcomes.

Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry? A) Alice J, RN B) A. Jones, RN C) Alice Jones D) AJRN

Ans: B Feedback: Each entry is signed with the first initial, last name, and title. In this case, A. Jones, RN, is correct.

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? A) Client assessment B) Intervention carried out C) Written plan of care D) Multidisciplinary interventions

Ans: B Feedback: In the PIE notes, the nurse documents the problem, intervention and evaluation. Thus the nurse would document the intervention carried out. Client assessment is not a part of the PIE notes, because this information is recorded on flow sheets for each shift. Although the PIE system uses a nursing plan-of-care format, there is no written plan of care. The PIE system is not multidisciplinary; it provides a documentation system for nursing only.

A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? A) PIE system B) Minimum data set C) OASIS D) Charting by exception

Ans: B Feedback: Long-term care documentation is specified by the RAI with the minimum data set forming the foundation for the assessment. This is required in all facilities certified to participate in Medicare or Medicaid. OASIS is used in the home health care industry.

A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to selfadminister the insulin injection. How would this outcome be evaluated? A) Asking the client to verbally repeat the steps of the injection B) Asking the client to demonstrate self-injection of insulin C) Asking family members how much trouble the client is having with injections D) Asking the client how comfortable he or she is with injections

Ans: B Feedback: Psychomotor outcomes describe the client's achievement of new skills and are evaluated by asking the client to demonstrate the new skill.

When a charge nurse evaluates the need for additional staff nurses and additional monitoring equipment to meet the client's needs, the charge nurse is performing an evaluation termed ... A) process evaluation B) structure evaluation C) outcome evaluation D) summary evaluation

Ans: B Feedback: Structure evaluation focuses on the attributes of the setting or surroundings where health care is provided.

A physician's order reads "up ad lib." What does this mean in terms of client activity? A) May walk twice a day B) May be up as desired C) May only go to the bathroom D) Must remain on bed rest

Ans: B Feedback: The abbreviation "up ad lib" means the client may be up as desired.

A nurse forgets to raise the bed railings of a client who is confused after taking pain medications. The client attempts to get out of bed, and suffers a minor fall. The nurse asks a colleague who witnessed the fall not to mention it to anyone because the client only had minor bruises. What would be the appropriate action of the colleague? A) No other steps need to be taken, since the client was not seriously injured. B) The colleague should inform the nurse that a full report of the incident needs to be made. C) The colleague should monitor the client closely for any adverse effects of the fall. D) The colleague should report the incident in a peer review of the nurse.

Ans: B Feedback: The colleague should tell the nurse that a full report needs to be made. If appropriate, the colleague could help the nurse identify what contributed to her not raising the bed railings in an effort to prevent it from happening in the future.

A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse? A) "I am sorry that you had to suffer this way. The nurse on night duty should be fired." B) "It's hard to be in bed and ask for help. You ring for a nurse who never seems to help." C) "You seem to be impatient. The nurses work very hard and they do whatever they can." D) "I can see that you are angry. What the nurse did is wrong, and it won't happen again."

Ans: B Feedback: The nurse should empathize with the client to perceive how the client is feeling. The nurse shares his or her perception with the client, which makes him comfortable to share his anxieties, fear, and concerns. The first response conveys pity on the client, which is inappropriate. In the third response, the nurse is taking the side of the nursing staff and the client may not like it. The fourth response is nontherapeutic.

What step in the nursing process is most closely associated with cognitively skilled nurses? A) Assessing B) Planning C) Implementing D) Evaluating

Ans: B Feedback: Cognitively skilled nurses are critical thinkers and are able to select those nursing interventions that are most likely to yield the desired outcomes.

Nurses make decisions in their practice every day. Which of the following are potential errors in this decision-making process? Select all that apply. A) Placing emphasis on the last data received B) Avoiding information contrary to one's opinion C) Selecting alternatives to maintain status quo D) Being predisposed to multiple solutions E) Prioritizing problems in order of importance

Ans: B, C Feedback: Potential errors in decision making include bias: placing emphasis on the first data received, avoiding information contrary to one's opinion, selecting alternatives to maintain status quo, and being predisposed to a single solution. Failure to prioritize problems in order of importance is failure to consider the total situation. Failure to use appropriate resources is impatience. All these actions can lead to errors in decision making (Lipe & Beasley, 2004.)

Which activity does the nurse perform during the evaluating stage? Select all that apply. A) Validates with the client the problem of constipation. B) Collects data to determine the number of catheter-associated infections on the nursing unit. C) Increases the frequency of repositioning from every two hours to every one hour. D) Sets a goal of ambulating from bed to room door and back to bed. E) Identifies smoking and sedentary lifestyle as risk factors for hypertension.

Ans: B, C Feedback: During the evaluation stage, the nurse modifies the plan of care if desired outcomes are not achieved (increased frequency of repositioning) and collects data, such as number of infections, to monitor quality and effectiveness of nursing practice. During the diagnosis stage, the nurse identifies factors contributing to the client's health problem, such as smoking and sedentary lifestyle, and validates the identified health problems (such as constipation) with the clients. The nurse establishes plan priorities and sets goals with the client and family during the outcome identification and planning.

Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? Select all that apply. A) Professional physicians' organizations B) State Nurse Practice Acts C) The Joint Commission D) The Agency for Health Care Research and Quality E) The Patient Health Partnership

Ans: B, C, D Feedback: To plan health care correctly, the nurse must be familiar with standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. These standards include the law, national practice standards, specialty professional nursing organizations, The Joint Commission, the Agency for Health Care Research and Quality, and employers.

The nurse is providing care for a client who experienced an ischemic stroke five days ago. Which of the following diagnoses would the nurse be justified in identifying and documenting in the care of this client? Select all that apply. A) Dysphagia B) Bowel Incontinence C) Impaired Swallowing D) Impaired Physical Mobility E) Risk for Hemiparesis

Ans: B, C, D Feedback: Bowel Incontinence, Impaired Swallowing, and Impaired Physical Mobility are all health problems that can be independently prevented or resolved by nursing practice. Dysphagia and hemiparesis are medical diagnoses.

A nurse is counseling a novice nurse who gives 150% effort at all times and is becoming frustrated with a health care system that provides substandard care to clients. Which of the following advice would be appropriate in this situation? Select all that apply. A) Tell the new nurse to help other nurses perform their jobs, thus ensuring quality client care is being delivered. B) Encourage the new nurse to leave her problems at work behind, instead of rehashing them at home. C) After establishing a reputation for delivering quality nursing care, have her seek creative solutions for nursing problems. D) Tell her to view nursing care concerns as challenges rather than overwhelming obstacles, and seek help for solutions. E) State that if resources do not permit quality care, it is not the role of the new nurse to explore change strategies within the institution.

Ans: B, C, D Feedback: The following items are good advice for nurses experiencing burnout: Learn to give quality care during designated work period; leave on time; avoid the temptation to do the work of others; and leave work concerns at work. After establishing a reputation for delivering quality nursing care, seek creative solutions for nursing problems (strategies to increase nursing resources, motivation, morale) and try them — hopefully with a support network. View concerns as challenges rather than overwhelming obstacles. Develop a realistic sense of how much nursing care (and of what quality) can be delivered with existing resources. If resources do not permit quality care, explore change strategies within the institution. If administration is not supportive, explore other practice settings.

In which of the following cases should a progress note be written? Select all that apply. A) For any nurse-client interaction B) When admitting a client C) When receiving a client postoperatively D) When assisting a client with ADLs E) When a procedure is performed

Ans: B, C, E Feedback: A progress note should be written in the following instances: upon admission, transfer to another unit, and discharge; when a procedure is performed; upon receiving a client postoperatively or postprocedure; upon communicating with physicians regarding critical client information (e.g., abnormal lab value result); or for any change in client status.

22. Which of the following statements accurately describes a recommended guideline for implementation? Select all that apply. A) When implementing nursing care, remember to act independently, regardless of the wishes of the client/family. B) Before implementing any nursing action, reassess the client to determine whether the action is still needed. C) Assume that the nursing intervention selected is the best of all possible alternatives. D) Consult colleagues and the nursing and related literature to see if other approaches might be more successful. E) Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.

Ans: B, D Feedback: When implementing nursing care, the nurse should act in partnership with the client/family and reassess the client to determine if the nursing action is still needed. The nurse should always question that the nursing intervention selected is the best of all possible alternatives. The nurse should consult colleagues and related nursing literature to see if other approaches might be more successful. The nurse should develop a repertoire of skilled nursing interventions, and check to make sure that the ones selected are consistent with standards of care and within legal/ethical guidelines to practice.

As a beginning student in nursing, what is essential to the mastery of technical skills, such as giving an injection? A) Read the steps of the procedure before clinical assignments. B) Even if you do not know how to give an injection, act as if you do. C) Practice giving injections in the learning laboratory until you feel comfortable. D) Tell your instructor that you don't think you can ever give an injection.

Ans: C Feedback: Before attempting to perform a technical skill with or on a patient, it is necessary for the nurse to practice that skill until he or she feels confident in doing it.

What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for clients within a case management health care delivery system? A) Kardex care plans B) Computerized plans of care C) Clinical pathways D) Student care plans

Ans: C Feedback: Clinical pathways (critical pathways, CareMaps) are tools used to communicate the standardized interdisciplinary plan of care for clients. The emphasis in case management is on clearly stating expected client outcomes and the specific times targeted to achieve these outcomes.

Which of the following illustrates a common error when writing client outcomes? A) Client will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m. B) Client will demonstrate correct sequence of exercises by next office visit. C) Client will be less anxious and fearful before and after surgery. D) On discharge, client will list five symptoms of infection to report.

Ans: C Feedback: Common errors when writing client outcomes include expressing the outcome as a nursing intervention, using verbs that are not observable and measurable (as is done here), and writing vague outcomes (also done here).

Based on an established plan of care, a nurse turns a client every two hours. What part of the nursing process is the nurse using? A) Assessing B) Planning C) Implementing D) Evaluating

Ans: C Feedback: During the implementing step of the nursing process, the nurse carries out interventions that were developed during the planning step.

When the nurse is administering Lasix 20 mg to a client in congestive heart failure, what phase of the nursing process does this represent? A) Assessment B) Planning C) Implementation D) Evaluation

Ans: C Feedback: Implementation refers to the action phase of the nursing process, in which nursing care is provided.

What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care? A) Problem statement B) Defining characteristics C) Etiology of the problem D) Outcomes criteria

Ans: C Feedback: In contrast to the client goals, which are suggested by the problem statement of the diagnosis, it is the cause of the problem (etiology) that suggests the nursing interventions. Effective nurses select nursing interventions that specifically address factors that cause, or contribute to, the client's problem.

Legally speaking, how would the nurse ensure that care was not negligent? A) Verbally reporting assessments to the client's physician B) Keeping private notes about the care given to each assigned client C) Documenting the nursing actions in the client's record D) Tape recording complete information for each oncoming shift

Ans: C Feedback: Legally speaking, a nursing action not documented in the client's record is a nursing action not performed. Unless the record contains written (not verbal, tape-recorded, or in private notes) documentation of care provided, the court would have no reason to accept a nurse's claim that the care was given.

Which of the following is a correctly written client goal? A) The client will eliminate a soft formed stool. B) The client understands what foods are low in sodium. C) The client will ambulate 10 feet with a walker by October 12. D) The client correctly self-administers the morning dose of insulin.

Ans: C Feedback: Outcomes are client-centered, use action verbs, identify measurable criteria, and include a time frame as to when the outcome should be achieved. A correctly written outcome will identify who (the client) will do what (ambulate), how well (10 feet), under what circumstances (with a walker), and by when (October 12). Understand is vague and not action-oriented. The outcomes regarding eliminating a stool and self-administering insulin are missing the time frame.

During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived? A) The defining characteristics B) The related factors C) The problem statement D) The database

Ans: C Feedback: Outcomes are derived from the problem statement of the nursing diagnosis. For each nursing diagnosis, at least one outcome should be written that, if achieved, demonstrates a direct resolution of the problem statement.

Which of the following group of terms best describes the nursing process? A) nursing goals, medical terminology, linear B) nurse-centered, single focus, blended skills C) patient-centered, systematic, outcomes-oriented D) family-centered, single point in time, intuitive

Ans: C Feedback: The nursing process is a patient-centered, systematic, outcomes-oriented method of caring that provides a framework for nursing practice. It is nursing practice in action.

Which of the following outcomes is correctly written? A) Abdominal incision will show no signs of infection. B) On discharge, client will be free of infection. C) On discharge, client will be able to list five symptoms of infection. D) During home care, nurse will not observe symptoms of infection.

Ans: C Feedback: To be measurable, outcomes should have a subject (client or part of the client), verb (action to be performed), conditions (not always included), performance criteria (observable, measurable), and target time (to achieve the outcome).

The nurse formulates the following client outcome: Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7. Which error has the nurse made? A) Expressed the client outcomes as a nursing intervention B) Wrote vague outcomes that will confuse other nurses C) Included more than one client behavior in the outcome D) Used verbs that are not observable and measurable

Ans: C Feedback: Two client behaviors have been included in the outcome statement: drawing up insulin and identifying four signs and symptoms.

Which of the following is one example of a client benefit of using the nursing process? A) Greater personal satisfaction B) Decreased reliance on the nursing staff C) Continuity of care D) Decreased incidence of medical errors

Ans: C Feedback: When used well, the nursing process achieves for the client scientifically based, holistic, individualized care; the opportunity to work collaboratively with nurses; and continuity of care.

A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? A) "Do you have a family history of chest problems?" B) "Why don't you use a laxative every night?" C) "Do you take anything to help your constipation?" D) "Everyone who ages has bowel problems."

Ans: C Feedback: A possible cause of omission of pertinent data is failing to follow up on cues during data collection. The nurse should ask about what the client uses to self-treat her constipation in order to identify further important information. It is not correct to ignore the statement, ask "why" questions, or make assumptions.

Of all the benefits of using nursing diagnoses, which one is probably the most important to nurses? A) Defining the domain of nursing practice B) Informing patients of their care C) Improving communication among nurses D) Structuring curricular content

Ans: C Feedback: Although all the choices are correct, improved communication among nurses and other health care professionals is probably the most important benefit that accurate, up-to-date nursing diagnoses offer nurses.

Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview? A) "Why didn't you go to the doctor when you began to have this pain?" B) "Are you feeling better now than you did during the night?" C) "Tell me more about what caused your pain." D) "If I were you, I would not wait to get medical help next time."

Ans: C Feedback: Avoid questions that impede communication during the interview, including those that can be answered by yes or no, why or how questions, and giving advice.

A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual? A) "Can you tell me how long your father has been this way?" B) "Sarah, I have to go and read your father's old charts before we talk." C) "Mr. Koeppe, tell me what you do to take care of yourself." D) "Mr. Koeppe, I know you can't answer my questions, but it's okay."

Ans: C Feedback: Clients such as older adults with dementia, and their children, cannot be relied on to report accurately. However, they should be encouraged to respond to interview questions as best as they can. Bypassing the client communicates that the nurse does not have time or has doubts in the client's ability to communicate.

6. A nurse practitioner is caring for a couple who are the parents of an infant diagnosed with Down Syndrome. The nurse makes referrals for a parent support group for the family. This is an example of which nursing role? A) Teacher/Educator B) Leader C) Counselor D) Collaborator

Ans: C Feedback: Counseling skills involve the use of therapeutic interpersonal communication skills to provide information, make appropriate referrals, and facilitate the patient's problem-solving and decision-making skills. The teacher/educator uses communication skills to assess, implement, and evaluate individualized teaching plans to meet learning needs of clients and their families. A leader displays an assertive, self-confident practice of nursing when providing care, effecting change, and functioning with groups. The collaborator uses skills in organization, communication, and advocacy to facilitate the functions of all members of the health care team as they provide patient care.

10. What activity is carried out during the implementing step of the nursing process? A) Assessments are made to identify human responses to health problems. B) Mutual goals are established and desired client outcomes are determined. C) Planned nursing actions (interventions) are carried out. D) Desired outcomes are evaluated and, if necessary, the plan is modified.

Ans: C Feedback: During the implementing step of the nursing process, nursing actions (interventions) planned during the planning step are carried out.

26. Which is a responsibility of the nurse in the nurse-client-family team relationship? A) Provide creative leadership to make the nursing unit a satisfying and challenging place to work. B) Support the nursing care given by other nursing and non-nursing personnel. C) Educate the family to be informed and assertive consumers of health care. D) Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

Ans: C Feedback: Educating the family to be informed and assertive consumers of health care is a role responsibility in the nurse-client-family relationship. Responsibilities of the nurse in the nurse-health care team relationship include coordinating the inputs of the multidisciplinary team into a comprehensive plan of care. In the nurse-nurse relationship, the nurse provides creative leadership to make the nursing unit a satisfying and challenging place to work, and supports the nursing care given by other nursing personnel.

4. Who is considered to be the founder of professional nursing? A) Dorothea Dix B) Lillian Wald C) Florence Nightingale D) Clara Barton

Ans: C Feedback: Florence Nightingale is considered to be the founder of professional nursing. She elevated the status of nursing to a respected occupation, improved the quality of nursing care, and founded modern nursing education. Although the other choices are women who were important to the development of nursing, none of them is considered the founder.

30. The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the nurse to perform? A) Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it means to be NPO. B) Seek input from the family of how the client with aphasia normally communicates at home. C) Respond to the postoperative client's question that baths are given only in the morning. D) Request that family members provide ethnic/cultural foods of the African client's liking.

Ans: C Feedback: Guidelines for implementing indicate that the nurse implements care that is culturally sensitive and individualized for the client. The nurse forms a partnership with the client and family when implementing care. The response by the nurse indicating a set time for baths is not reflective of being open to individualizing client care. The other options are consistent with the guidelines for implementing.

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct? A) "needs nasal oxygen to improve breathing" B) "cough related to ineffective airway clearance" C) "ineffective airway clearance related to thick mucus" D) "refuses to cough and expectorate thick mucus"

Ans: C Feedback: It is important to use guidelines to formulate correctly written nursing diagnoses. The nurse would not use client needs, put defining characteristics before the diagnoses, or judge the willingness of the client to cough.

The nurse is reviewing information about a client and notes the following documentation Client is confused. The nurse recognizes this information is an example of what? A) Subjective data B) A data cue C) An inference D) Primary data

Ans: C Feedback: Making a judgment that the client is confused is an inference. An inference must be validated with subjective and/or objective data cues. Sources of data cues can be primary or secondary.

A student is reviewing a client's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis? A) Neither appendicitis nor acute pain B) Both appendicitis and acute pain C) Appendicitis D) Acute pain

Ans: C Feedback: Medical diagnoses identify diseases (in this case, appendicitis). Nursing diagnoses describe problems treated by the nurse within the scope of independent nursing practice.

A nurse is reviewing the health history and physical assessment findings for a client who is having respiratory problems. Of the following data collected, what data from the health history would be a cue to a nursing diagnosis for this problem? A) "I often have diarrhea after I eat spicy foods." B) "My skin is so dry I just can't keep from scratching." C) "I get out of breath when I walk a few steps." D) "I just feel so bad about myself these days."

Ans: C Feedback: Most experienced nurses begin the work of interpreting and analyzing data while they are still collecting it. The term cue is often used to denote significant data, which "raises a red flag" to look for patterns or clusters of data that signal a nursing diagnosis. In this instance, the client's statement of getting out of breath when walking would be a cue to assess other subjective and objective data related to the respiratory system.

16. The staff in a long-term care facility often plays loud rock music on the radio and designs children's games as exercise. What is the staff doing in this situation? A) Considering the hearing level of older adults B) Failing to consider visual deficits that occur with aging C) Ignoring the developmental needs of older adults D) Meeting needs for sensory input and exercise

Ans: C Feedback: Nurses must be careful not to let stereotypes about developmental stages and tasks influence client care. Playing loud rock music and designing children's games ignore the older adults' needs and is demeaning.

11. What role of the nurse is crucial to the prevention of fragmentation of care? A) Advocate B) Educator C) Counselor D) Coordinator

Ans: C Feedback: One of nursing's major contributions to the health care team is the role of coordinator. Care can easily become fragmented when clients are seen by numerous specialists—each interested in a different aspect of the client. It is important for the nurse to make rounds with other health care professionals and to read the results of consultations that clients have had with specialists. They can then interpret the specialists' findings for clients and family members, prepare clients to participate maximally in the plan of care before and after discharge, and serve as a liaison among the members of the health care team.

12. A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean? A) The nurse is using critical thinking to implement the dressing change. B) The client has specified how the dressing should be changed. C) Written plans are developed that specify nursing activities for this skill. D) The physician verbally requested specific steps of the dressing change.

Ans: C Feedback: Protocols (written plans that detail the nursing activities to be executed in specific situations) are nurse-initiated interventions. They expand the scope of nursing practice in certain clearly defined situations.

Of the following information collected during a nursing assessment, which are subjective data? A) vomiting, pulse 96 B) respirations 22, blood pressure 130/80 C) nausea, abdominal pain D) pale skin, thick toenails

Ans: C Feedback: Subjective data are information perceived only by the affected person. They cannot be perceived or verified by another person. Other terms for subjective data are symptoms or covert data.

11. After graduation from an accredited program in nursing and successfully passing the NCLEX, what gives the nurse a legal right to practice? A) Enrolling in an advanced degree program B) Filing NCLEX results in the county of residence C) Being licensed by the State Board of Nursing D) Having a signed letter confirming graduation

Ans: C Feedback: The Board of Nursing in each state has the legal authority to allow graduates of approved schools of nursing to take the licensing examination. Those who successfully meet the requirements for licensure are given a license to practice nursing in the state. It is illegal to practice nursing without a license issued by the State Board of Nursing. A nurse does not have the legal right to practice nursing by enrolling in an advanced degree program, filing NCLEX results, or having a letter confirming graduation.

A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan? A) Risk for impaired physical mobility due to surgery B) Ineffective denial related to poor coping mechanisms C) Disturbed body image related to the incision scar D) Risk of injury related to surgical outcomes

Ans: C Feedback: The client is concerned about the surgery scar on his neck, which would disturb his body image; therefore, the appropriate diagnosis should be disturbed body image related to the incision scar. Risk for impaired physical mobility may be present after surgery, but is not related to the concerns expressed by the client. Likewise, ineffective denial related to poor coping mechanisms, and injury related to surgical outcomes are also not related to the client's concern.

12. A health care facility determined that a nurse employed on a medical unit was documenting care that was not being given, and subsequently reported the action to the State Board of Nursing. How might this affect the nurse's license to practice nursing? A) It will have no effect on the ability to practice nursing. B) The nurse can practice nursing at a less-skilled level. C) The nurse's license may be revoked or suspended. D) The nurse's license will permanently carry a felony conviction.

Ans: C Feedback: The license and the right to practice nursing can be denied, revoked, or suspended for professional misconduct, such as a crime. Other areas of professional misconduct include incompetence, negligence, and chemical impairment. Committing a felony does affect the legal right to practice nursing, does not allow the nurse to practice at a lower level, and is not attached to the license.

While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which of the following actions clearly demonstrates assessing? A) The nurse bathing the client B) The nurse documenting the incident C) The nurse asking if the client is having pain D) The nurse removing the wash basin

Ans: C Feedback: The nurse asking if the client is having pain clearly demonstrates assessing. Bathing the client and removing the wash basin demonstrate implementation. Documentation is part of every step of nursing process.

27. The nurse is caring for a client with a diagnosis of colon disease. The client has expressed to various members of the health care team the desire to be kept comfortable and to not continue further treatment. The client asks the nurse to be present when the client discusses the decision with other family members. In which professional nursing relationship is the nurse participating? A) Nurse-client B) Nurse-nurse C) Nurse-client-family D) Nurse-health care team

Ans: C Feedback: The nurse is fulfilling role responsibilities of the nurse-client-family relationship when being present for a discussion of the matter by the client and family.

14. A nurse is caring for a client who is a chronic alcoholic. The nurse educates the client about the harmful effects of alcohol and educates the family on how to cope with the client and his alcohol addiction. Which of the following skills is the nurse using? A) Caring B) Comforting C) Counseling D) Assessment

Ans: C Feedback: The nurse is using counseling skills to educate the client about the harmful effects of alcohol. The nurse can also suggest rehabilitative care for the client. The nurse uses therapeutic communication techniques to encourage verbal expression and to understand the client's perspective. Caring, comforting, and assessment may require active listening, but counseling is based upon the active listening and interaction between the client and the counselor.

In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process? A) To collect information about subjective and objective data B) To correlate nursing and medical diagnostic criteria C) To identify etiologies of health problems D) To evaluate mutually developed expected outcomes

Ans: C Feedback: The purpose of diagnosing, the second step in the nursing process, is to identify how an individual, a group, or a community responds to actual or potential health and life processes; to identify etiologies (factors that contribute to or cause health problems); and to identify resources or strengths that the individual, group, or community can draw on to prevent or resolve problems.

Which of the following statements accurately describes the legal responsibility of the nurse making a diagnosis for a client? A) The nurse may make a diagnosis, but the physician is responsible for making sure it is appropriate for the client. B) The nurse practitioner is responsible for making all nursing diagnoses and determining if they are appropriate for the client. C) The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept responsibility for treating it. D) The health care facility directs the nursing diagnosis in order to receive payment for services performed.

Ans: C Feedback: The term diagnosis means there is a problem requiring qualified treatment. The nurse must decide if he or she is qualified to make the diagnosis and will be able to treat it. If not, the nurse must refer the client to a qualified person for treatment.

A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment? A) Comprehensive B) Focused C) Time-lapsed D) Emergency

Ans: C Feedback: The time-lapsed assessment is scheduled to compare a client's current status to baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time, such as homebound clients with visiting nurses, are scheduled for periodic time-lapsed assessments to reassess health status and to make necessary revisions in the plan of care.

18. A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse? A) The UAP is responsible and accountable for his or her own actions. B) Nurses do not have authority to delegate interventions. C) The nurse transfers responsibility but is accountable for the outcome. D) The UAP can function in an independent role for all interventions.

Ans: C Feedback: UAPs are trained to function in an assistive role to the RN in client activities as delegated and supervised by the RN. Delegation is the transfer of responsibility of an activity to another individual while retaining accountability for the outcome.

A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent? A) PIE note B) Flow sheet C) Narrative note D) SOAP note

Ans: C Feedback: A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client's response.

The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. This is an example of what type of outcome? A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome

Ans: C Feedback: Physiologic outcomes are physical changes in the client, such as pulse oximetry. An affective outcome involves changes in the client's values, beliefs, and attitude. Cognitive outcomes demonstrate increases in client knowledge. Psychomotor outcomes describe the client's achievement of new skills.

The nurse participates in a quality assurance program. Data from the previous year indicates a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. The nurse recognizes this is which type of evaluation? A) Design evaluation B) Process evaluation C) Outcome evaluation D) Structure evaluation

Ans: C Feedback: Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. Structure evaluation focuses on the environment in which care is provided, whereas process evaluation focuses on the nature and sequence of activities carried out by implementing the nursing process. There is no design evaluation.

A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next? A) Date it and put it in the client's record. B) Sign it and put it in the Kardex. C) Individualize it to the specific client. D) Use it as printed, based on common needs.

Ans: C Feedback: Standardized care plans that identify common problems and needs with relation to select client cohorts may be used. Unless such care plans are individualized to a specific client, however, they may not address individual client needs.

A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as the firststep? A) Plan of care B) Data, action, and response C) Problem selected D) Nursing activities during a shift

Ans: C Feedback: The SOAP method begins by selecting a problem from a list. PIE (problems, interventions, and evaluation) notes incorporate the plan of care into the progress notes. Focus DAR notes organizes entries by data, action, and response. The narrative notes are used to record relevant client and nursing activities throughout a shift.

What is the nurse's best defense if a client alleges nursing negligence? A) Testimony of other nurses B) Testimony of expert witnesses C) Client's record D) Client's family

Ans: C Feedback: The client record is the only permanent legal document that details the nurse's interactions with the client. It is the best defense if a client or client surrogate alleges nursing negligence.

Which of the following data entries follows the recommended guidelines for documenting data? A) "Client is overwhelmed by the diagnosis of pancreatic cancer." B) "Client's kidneys are producing sufficient amount of measured urine." C) "Following oxygen administration, vital signs returned to baseline." D) "Client complained about the quality of the nursing care provided on previous shift."

Ans: C Feedback: The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.

A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which of the following would be most appropriate for the nurse to do? A) Completely erase or delete the erroneous entry if possible. B) Use a highlighter to mark the incorrect entry and place initials next to it. C) Strike out the entry with a single line, place initials next to it, and write the correct entry. D) Black out the erroneous entry with a dark pen or marker.

Ans: C Feedback: The nurse should strike out the erroneous entry with a single line and place initials over it. When an error occurs, erasure or use of correction fluid is not permissible. Use of highlighters is not allowed and can draw attention to the erroneous documentation.

A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply. A) Carrying out a physician's order to intubate a client B) Educating a novice nurse on the principles of triage C) Using the nursing process to diagnose a blocked airway D) Interviewing privately a client suspected of being a victim of abuse E) Checking with the family about the data supplied by a client suffering from dementia

Ans: C, D, E Feedback: Since the entire nursing process rests on the initial and ongoing assessment of the client, it is imperative to use excellent critical thinking skills when gathering, validating, analyzing, and communicating data. The nurse using critical thinking skills assesses information systematically using the nursing process, detects biases, makes judgments about the significance of data, and identifies assumptions and inconsistencies. Carrying out physician's orders and educating a novice nurse involve the implementation stage of the nursing process.

21. A registered nurse who provides care in a subacute setting is responsible for overseeing and delegating to unlicensed assistive personnel (UAP). Which of the following principles should the nurse follow when delegating to UAP? Select all that apply. A) Ensure that UAPs closely follow the nursing process when providing care. B) Audit the client documentation that UAPs record after they perform interventions. C) Take frequent mini-reports from UAPs to ensure changes in client status are identified. D) Know what clinical cues the UAP should be alert for and why. E) Make frequent walking rounds to assess clients.

Ans: C, D, E Feedback: The nurse must take careful action to ensure that delegation results in safe and competent client care. This necessitates such measures as taking frequent mini-reports, identifying the clinical cues that UAPs should be aware of, and performing rounds often. UAPs are not normally educated to follow the nursing process nor to perform documentation.

Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client's situation? A) Kardex B) Case management C) Critical pathways D) Concept map care plan

Ans: D Feedback: A concept map care plan is a diagram of client problems and interventions. The nurse's ideas about client problems and treatments are the "concepts" that are diagrammed. These maps are used to organize client data, analyze relationships in the data, and enable the nurse to take a holistic view of the client's situation (Schuster, 2002).

Members of the staff on a hospital unit are critical of a client's family, who has different cultural beliefs about health and illness. A student assigned to the patient does not agree, based on her care of the client and family. What critical-thinking attitude is the student demonstrating? A) Being curious and persevering B) Being creative C) Demonstrating confidence D) Thinking independently

Ans: D Feedback: Although all the attitudes listed are components of critical thinking, the student is thinking independently. Nurses who are independent thinkers are careful not to let the status quo or a persuasive individual control their thinking.

Which of the following interpersonal skills is essential to the practice of nursing? A) Performing technical skills knowledgeably and safely B) Maintaining emotional distance from clients and families C) Keeping personal information among shared clients confidential D) Promoting the dignity and respect of patients as people

Ans: D Feedback: Characteristics of interpersonal caring that are essential to the practice of nursing include promoting the dignity and respect of clients as people, the centrality of the caring relationship, and a mutual enrichment of both participants in the nurse-client relationship.

What is the primary purpose of the outcome identification and planning step of the nursing process? A) To collect and analyze data to establish a database B) To interpret and analyze data so as to identify health problems C) To write appropriate client-centered nursing diagnoses D) To design a plan of care for and with the client

Ans: D Feedback: The primary purpose of outcome identification and planning is to design a plan of care for (and with) the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes.

23. A registered nurse adheres to the American Nurses Association's standard of professional performance by engaging in which of the following? A) Assessment B) Diagnosis C) Evaluation D) Collaboration

Ans: D Feedback: Collaboration is designated in ANA's standard of professional performance. Assessment, diagnosis, and evaluation are not designated in ANA's standard of professional performance. They are professional nursing responsibilities designated in ANA's standard of care list.

A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse about the baby's strengths? A) Nothing; this observation is not important. B) The mother is just behaving as all mothers do. C) A baby is not capable of having strengths. D) Nurturing is a strength for developing infants.

Ans: D Feedback: A strength, as assessed by the nurse during data interpretation and analysis, contributes to a client's level of wellness. In this case, the obvious love of the mother for her baby indicates a significant strength in the normal growth and development of the baby.

31. Nursing students need to learn to nurse themselves in order to prepare to be professional nurses. Which activities would fail to prepare nursing students for the delivery of nursing care? A) Time management, communication, and establishing a support system. B) Establishing a support system, a sense of humor, and self-awareness. C) Self-awareness, preparation for crisis, and stress management. D) A sense of humor, anticipation of loss, and developing negative body image.

Ans: D Feedback: Activities that would prepare nursing students for the delivery of nursing care include time management, communication, establishing a support system, self-awareness, stress management, a sense of humor, and preparation for crisis and loss. Negative body image is not desired.

A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving home care for treatment of metastatic cancer. What statement or question would be best to validate this client problem? A) "I have assessed you and find you are fatigued." B) "I analyzed and interpreted your information as fatigue." C) "Why are you so tired all the time?" D) "I think fatigue is a problem for you. Do you agree?"

Ans: D Feedback: After a tentative nursing diagnosis is made, it should be validated. Clients who are able to participate in decision making should be encouraged to validate the diagnosis.

18. A registered nurse assigns the task of tracheostomy suctioning of a client to the LPN. The LPN informs the nurse that she has never done the procedure practically on a client. What should be the most appropriate response from the registered nurse? A) "You are through with your theory class, so you should know." B) "Take the help of the nurse who knows to perform the procedure." C) "Take the help of the procedure manual and act accordingly." D) "I will help you in performing the procedure on the client."

Ans: D Feedback: Although the registered nurse has assigned the task to the LPN, the overall responsibility lies with the registered nurse. The registered nurse is answerable for the client's care, not the LPN. Telling the LPN that she should know the procedure because it is taught in class is inappropriate; putting theory into application would require supervision. Asking the LPN to refer to the manual and perform the procedure is incorrect because the LPN may commit mistakes. The LPN is not confident about the procedure and therefore should not be asked to do the task alone or with another nurse who knows the procedure.

The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment? A) To gather data about a specific and current health problem B) To identify life-threatening problems that require immediate attention C) To compare and contrast current health status to baseline data D) To establish a database to identify problems and strengths

Ans: D Feedback: An initial assessment is performed shortly after the client is admitted to a health care agency or service. The purpose of the initial assessment is to establish a complete database for problem identification and care planning.

A nurse develops a plan of care to meet the needs of a client who has had a large loss of blood after a snowmobile crash. Intravenous fluids and blood are administered and the nurse monitors the client's physiologic response. This action is known as a: A) medical diagnosis. B) nursing diagnosis. C) goal for care. D) collaborative problem.

Ans: D Feedback: Collaborative problems are certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems by using physician-prescribed and nursing-prescribed interventions to minimize the complications of the event.

A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide organization or ... A) Categorizing B) Diagnosing C) Grouping D) Clustering

Ans: D Feedback: Cue clustering brings together cues that if viewed separately would not convey the same meaning.

33. Which nursing role is the nurse exhibiting when collecting data about the number of urinary tract infections on the nursing unit? A) Advocate B) Leader C) Counselor D) Researcher

Ans: D Feedback: Data collection is part of the research process. As an advocate, the nurse would implement actions to protect the rights of the client. Counseling involves the use of therapeutic, interpersonal communication skills to provide information, make appropriate referrals, and facilitate client problem-solving and decision-making skills. A nurse leader is assertive and self-confident when providing care, effecting change, and functioning within groups.

Ch 15 Which of the following is a correct guideline to follow when composing a nursing diagnosis statement? A) Incorporate subjective and judgmental terminology. B) Phrase the nursing diagnosis as a client need. C) Place the etiology prior to the client problem and linked by the phrase "related to." D) Place defining characteristics after the etiology and link them by the phrase "as evidenced by."

Ans: D Feedback: Defining characteristics should follow the etiology and be linked by the phrase "as evidenced by" when included in the nursing diagnosis. The nursing diagnosis should be phrased as a client problem or alteration in health state, rather than as a client need. The client problem precedes the etiology and is linked by the phrase "related to." Avoid using judgmental language and write in legally advisable terms.

35. What characteristic of a competent nurse practitioner enables nurses to be role models for clients? A) Sense of humor B) Writing ability C) Organizational skills D) Good personal health

Ans: D Feedback: Good personal health enables nurses not only to practice more efficiently, but also to be a health model for clients and their families. Nurses can help clients to imitate good health behaviors, and eventually integrate them into their daily life through the process of identification.

A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself? A) Standing at the end of the bed B) Standing at the side of the bed C) Sitting at least six feet from the beside D) sitting at a 45-degree angle to the bed

Ans: D Feedback: If the patient is in bed, placing a chair at a 45-degree angle is helpful in facilitating an easy exchange of information. If the nurse stands at the side or foot of the bed and physically looks down at the client, a superior-inferior relationship is communicated and can negatively affect the interview.

17. A nurse administers a medication for pain but forgets to document it in the client's medical record. Legally, what does this mean? A) Nothing, the nurse's honesty will not be questioned. B) The nurse can add the documentation after the client goes home. C) The physician will verify that the nurse carried out the order. D) In the eyes of the law, if it is not documented, it was not done.

Ans: D Feedback: Nurses must carefully document each intervention. The legal truth is "if it wasn't documented, it wasn't done."

13. A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? A) To implement evidence-based practice B) To ensure the order follows hospital policy C) To be sure interventions are individualized D) To be sure the intervention is safe

Ans: D Feedback: Nurses reassess the client and review the plan of care before initiating any nursing intervention. This is done to make sure that the plan of care is still responsive to the client's needs, and is safe for the particular client. In this case, the nurse would not give oral fluids to an unconscious client.

13. While providing care to the diabetic patient the nurse determines that the patient has a knowledge deficit regarding insulin administration. This nursing action is described in which phase of the nursing process? A) evaluation B) implementation C) planning D) nursing diagnosis

Ans: D Feedback: Nursing focuses on human responses to actual or potential health problems. Identifying the problems occur in the nursing diagnosis phase. Mutually establishing expected outcomes with the patient occurs in the planning phase. Implementation of the individualized interventions, and evaluation of outcomes are also phases in the nursing process.

33. The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the nursing students indicates further education is required? A) Nursing interventions must be consistent with standards of care and research findings. B) Nursing interventions must be culturally sensitive and individualized for the client. C) Nursing interventions must be compatible with other therapies planned for the client. D) Nursing interventions must be approved by other members of the health care team.

Ans: D Feedback: Nursing interventions should be based on the etiology in the nursing diagnosis, be compatible with other planned therapies, be consistent with standards of care and research, and individualized for the client. Nursing interventions can be independent, dependent, and interdependent. Independent nursing interventions are nurse-initiated interventions directed at the etiology of the client problem; they do not require approval from other members of the health care team.

10. Which of the following is a criteria that defines nursing as profession? A) an undefined body of knowledge B) a dependence on the medical profession C) an ability to diagnose medical problems D) a strong service orientation

Ans: D Feedback: Nursing is recognized increasingly as a profession based on the following defining criteria: well-defined body of specific and unique knowledge; strong service orientation; recognized authority by a professional group; code of ethics; professional organization that sets standards; ongoing research; and autonomy.

A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? A) "My leg hurts so bad. I can't stand it." B) "Appears anxious and frightened." C) "I am so sick; I am about to throw up." D) "Unable to palpate femoral pulse in left leg."

Ans: D Feedback: Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same client. Objective data are also called signs or overt data. The only objective data in this question would be that the nurse is unable to palpate a femoral pulse.

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure? A) Ineffective airway clearance B) Ineffective coping C) Impaired urinary elimination D) Risk for body image disturbance

Ans: D Feedback: Risk for disturbed body image is the least priority among all the nursing diagnoses mentioned, according to the Maslow's hierarchy. Body image disturbance is not vital for life. Secondly, it is a potential diagnosis, not an actual diagnosis. The other options could be an actual diagnosis present in the client. Ineffective airway clearance is the most important diagnosis because it is vital to life. Impaired urinary elimination is the next most important diagnosis because it is a physiological need. Ineffective coping is a social need, followed by the least important diagnosis of disturbed body image.

27. The director of nursing (DON) of a major hospital is seeking to hire a nurse with a strong technical background to care for patients on a busy surgical unit. The DON is most likely going to hire a nurse prepared at which level of nursing? A) Doctoral level B) Master's level C) Baccalaureate level D) Associate level

Ans: D Feedback: The ANA's 1965 resolution prompted the 1985 ANA statement adopting the titles of associate nurse (a nurse prepared in an associate degree program with an emphasis on technical practice) and professional nurse (a nurse possessing the baccalaureate degree in nursing) for these two levels. Master's and doctoral prepared nurses possess higher degrees and expertise.

28. A student is choosing her educational path and desires a nursing degree with a track that contains community nursing and leadership, as well as liberal arts. The student would best be suited in which type of program? A) Licensed practical nursing program B) Certification in a nursing specialty C) Diploma nursing program D) Baccalaureate program

Ans: D Feedback: The baccalaureate degree in nursing offers students a full college or university education with a background in the liberal arts.

15. A nurse is caring for a client with quadriplegia who is fully conscious and able to communicate. What skills of the nurse would be the most important for this client? A) Comforting B) Assessment C) Counseling D) Caring

Ans: D Feedback: The client needs assistance in performing activities of daily life. This would require implementation of caring skills from the nurse. Comforting, counseling, and assessment skills are also required, but the priority is the caring skill. Comforting skills involve providing safety and security to the client, whereas counseling skills are implemented while providing health education and emotional support. Assessment skills would be required when collecting data from the client.

29. The nursing student is caring for a Native American client who is admitted for deep vein thrombosis. The nursing student speaks with a nurse regarding the client's lack of eye contact with the student. The nurse responds that Native Americans view eye contact as an invasion of privacy. Which error did the nursing student make? A) Failure to act in partnership with the client. B) Failure to approach the client caringly. C) Failure to seek the client's input in the plan of care. D) Failure to provide culturally sensitive care.

Ans: D Feedback: The nursing student failed to provide culturally sensitive care by expecting the client to engage in eye contact. There is no information to suggest the nursing student failed to act in partnership with the client, approach the client caringly, or seek the client's input in the plan of care.

A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over left side of face. What does the phrase "Disturbed Self-Esteem" identify? A) The expected outcome of the plan of care B) A cue to determining a health problem C) The major defining characteristic of a health problem D) The health state or problem of the client

Ans: D Feedback: The problem, a part of a nursing diagnosis, describes the health state or health problem of the client as clearly and concisely as possible. It identifies what is unhealthy about the client and what the client would like to change. It also suggests client outcomes but is not an outcomes statement.

7. A nurse is providing nursing care in a neighborhood clinic to single, pregnant teens. Which of the following actions is the best example of using the counselor role as a nurse? A) Discussing the legal aspects of adoption for teens wishing to place their infants with a family B) Searching the Internet for information on child care for the teens who wish to return to school C) Conducting a client interview and documenting the information on the client's chart D) Referring a teen who admits having suicidal thoughts to a mental health care specialist

Ans: D Feedback: The role of the counselor includes making appropriate referrals. Discussing legal issues is the role of the advocate and searching for information on the Internet is the role of a researcher. Conducting a client interview would fall under the role of the caregiver.

Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process? A) Trust clinical judgment and experience over asking for help. B) Respect clinical intuition, but never allow it to determine a diagnosis. C) Recognize personal biases as a strength in formulating diagnoses. D) Keep an open mind and trust your intuition when formulating diagnoses.

Ans: D Feedback: To correctly diagnose health problems, the nurse must be familiar with nursing diagnoses and other health problems; read professional literature and keep reference guides handy; trust clinical experience and judgment but be willing to ask for help when the situation demands more than his or her qualifications and experience can provide; respect clinical intuitions, but before writing a diagnosis without evidence, increase the frequency of observations and continue to search for clues to verify intuition. The nurse must also recognize personal biases and keep an open mind.

21. Training schools for nurses were established in the United States after the Civil War. The standards of U.S. schools deviated from those of the Nightingale paradigm. Which of the following statements is true about U.S. training schools? A) Training schools were affiliated with a few select hospitals. B) Training of nurses provided no financial advantages to the hospital. C) Training was formal, based on nursing care. D) Training schools eliminated the need to pay employees.

Ans: D Feedback: Training schools in the U.S. profited by eliminating the need to pay employees because students worked without pay in return for training, which usually consisted of chores. U.S. training schools were established by any hospital; there was no formal training. Training was an outcome of work, which eliminated the need to pay employees. Nightingale training schools were affiliated with a few select hospitals, training of nurses provided no financial advantages to the hospital, and the training was formal, based on nursing care.

15. A student is ambulating a client for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome? A) Take the client's vital signs after ambulation. B) Ask the client's wife to assist with ambulation. C) Delay ambulation until the following shift. D) Ask another student to help with ambulation.

Ans: D Feedback: Unexpected outcomes do occur, such as the risk of a fall for the postoperative client who is ambulated for the first time. In anticipation, the student caregiver could ask another student to help ambulate the client, thus decreasing this risk.

What is the primary purpose of validation as a part of assessment? A) To identify data to be validated B) To establish an effective nurse-client communication C) To maintain effective relationships with coworkers D) To plan appropriate nursing care

Ans: D Feedback: Validation is the act of confirming or verifying to plan appropriate nursing care. Validation is an important part of assessment because invalid information can lead to inappropriate nursing care. Validation does not identify data to be validated, nor does it establish effective nurse-client communication or relationships with coworkers.

The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect? A) Assessment B) Outcome identification C) Implementation D) Evaluation

Ans: D Feedback: Assessing the client's response to a diuretic medication is an example of evaluation. During assessment, the nurse collects and synthesizes data to identify patterns. The nurse establishes desired outcomes with the client and family during the outcome identification and planning stage. The nurse initiates activities to achieve the desired outcomes during the implementation stage.

A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this? A) Psychomotor B) Affective C) Physiologic D) Cognitive

Ans: D Feedback: Cognitive goals involve increasing client knowledge. These goals may be evaluated by asking clients to repeat information or to apply new knowledge in their everyday lives.

What activity in charting will assist most in the avoidance of errors? A) Objectivity B) Organization C) Legibility D) Timeliness

Ans: D Feedback: Documentation in a timely manner can help avoid errors.

The client's expected outcome is The client will maintain skin integrity by discharge. Which of the following measures is best in evaluating the outcome? A) The client's ability to reposition self in bed. B) Pressure-relieving mattress on the bed. C) Percent intake of a diet high in protein. D) Condition of the skin over bony prominences.

Ans: D Feedback: During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse examines client data or behaviors that validate whether the outcome is met. The condition of the skin, especially over bony prominences, provides the best measure of whether skin integrity has been maintained.

An expected client outcome is, The client will remain free of infection by discharge. When evaluating the client's progress, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000, and the client's abdominal wound has a half-inch gap at the lower end with yellow-green discharge. Which statement would be an appropriate evaluation statement? A) Goal partially met; client identified fever and presence of wound discharge. B) Client understands the signs and symptoms of infection. C) Goal partially met; client able to perform activities of daily living. D) Goal not met; white blood cell count elevated, presence of yellow-green discharge from wound.

Ans: D Feedback: During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse has three options: met, partially met, or not met. An elevated white blood cell count and the presence of yellow-green wound discharge are clinical manifestations consistent with an infectious process, so the outcome has not been met.

A nurse is documenting the intensity of a client's pain. What would be the most accurate entry? A) "Client complaining of severe pain." B) "Client appears to be in a lot of pain and is crying." C) "Client states has pain; walking in hall with ease." D) "Client states pain is a 9 on a scale of 1 to 10."

Ans: D Feedback: Information should be documented in a complete, accurate, relevant, and factual manner. Avoid interpretations of behavior, generalizations, and words such as "good."

A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called? A) Nursing care conferences B) Staff visits C) Interdisciplinary referrals D) Nursing care rounds

Ans: D Feedback: Nursing care rounds are procedures in which a group of nurses visits select clients individually at each client's bedside. The primary purposes are to gather information to help plan and evaluate nursing care and to provide the client with an opportunity to discuss care.

The nurse participates in a quality assurance program and reviews evaluation data for the previous month. Which of the following does the nurse recognize as an example of process evaluation? A) A 10% reduction in the number of ventilator-associated pneumonia B) A 5% increase in the number of nosocomial catheter-related urinary tract infections C) 40% of all client rooms in the facility are private and equipped with a computer D) A nursing care plan was developed within the eight hours of admission for 97% of all admissions.

Ans: D Feedback: Process evaluation focuses on the nature and sequence of activities carried out by nurses implementing the nursing process, such as the timing of nursing care plan creation. Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as the number of ventilator-associated pneumonia and nosocomial catheter-related urinary tract infections. Structure evaluation focuses on the environment in which care is provided, such as the number of private rooms equipped with a computer.

When a nursing supervisor evaluates the staff nurse's performance with a group of clients to whom the staff nurse has provided nursing care, the supervisor is performing which type of evaluation? A) Outcome evaluation B) Summary evaluation C) Structure evaluation D) Process evaluation

Ans: D Feedback: Process evaluation focuses on the nurse's performance and whether the nursing care provided was appropriate and competent.

The nurse is caring for the client with pneumonia. An expected client outcome is, The client will maintain adequate oxygenation by discharge. Which outcome criterion indicates the goal is met? A) Client taking antibiotic as ordered. B) Client identifies signs and symptoms of recurrence of infection. C) Client coughing and deep breathing every one hour. D) Client no longer requires oxygen.

Ans: D Feedback: The client who is maintaining adequate oxygenation would not require oxygen. The client could be able to do the other three options and still have problems with oxygenation.

What part of the client's record is commonly used to document specific client variables, such as vital signs? A) Progress notes B) Nursing notes C) Critical paths D) Graphic record

Ans: D Feedback: The graphic record is a form used to document specific client variables such as vital signs, weight, intake and output, and bowel movements.

A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports? A) Pay courtesy calls to staff members before attending the meeting. B) Wait for the physicians to arrive before exchanging notes. C) Avoid asking questions related to the medical record. D) Come prepared with material required to take notes.

Ans: D Feedback: The nurse should come prepared with material required to take notes during the change-of-shift reports. The nurse should not delay the meeting for change-of-shift report by paying courtesy calls to staff members before attending the meeting. Change-of-shift reports are not conducted in the presence of physicians, thus the nurse does not need to wait for the physicians to arrive before exchanging notes. The nurse should ask questions related to the medical record if any information is unclear.

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation? A) Erase the incorrect statement and write the correct one. B) Cross out the wrong statement in a way that is not readable. C) Use correction fluid to obliterate what has been written. D) Cross out the incorrect statement with a single line.

Ans: D Feedback: When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one, nor cross out the wrong statement in a way that makes the statement unreadable, nor use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.

Nursing is a profession in a rapidly changing health care environment. What is the most important reason for the nurse to develop critical thinking and clinical reasoning? A) To be able to employ the nursing process in client care. B) The licensing examination requires nurses to be adept at critical thinking. C) Because clients deserve experts who know how to care for them. D) To provide quality care with nursing ability and knowledge.

Ans: D ack: The goal of all nursing is to meet the standard of quality care. Clinical reasoning and critical thinking may be applied in all of the answers but the most important goal in health care is to provide quality nursing care to clients.

The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client's breathing is easier. The nurse is engaging in which phase of the nursing process? A) Assessment B) Diagnosing C) Planning D) Implementing E) Evaluating

Ans: E Feedback: The nurse is collecting evaluative data to determine whether or not the client is achieving the therapeutic response to the bronchodilator.

A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern? A) Impaired physical mobility B) Disturbed body image C) Risk for infection D) Risk for social isolation

ans: B Feedback: The diagnosis of disturbed body image is appropriate for the client because he is worried about the appearance of his legs due to swelling and the external fixation device. There is no mention about impaired physical mobility or risk for social isolation in the client's concern. There may be a risk of infection, but the client does not mention it.