Chapter 2: Nursing Process: Prep U Questions

A nurse cares for a client with congestive heart failure. The nurse administers a prescribed dose of furosemide intravenously after noting an increase in dyspnea and audible wheezing. The nurse's action demonstrates which step in the nursing process?

implementation

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:

uses critical thinking to direct care for the individual client.

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

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

The nurse performs discharge teaching for a client. How would the nurse best evaluate the effectiveness of the discharge teaching?

Ask the client to repeat back to the nurse how care will be conducted at home.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's appropriate first action?

Assess the client to determine the cause of the pain.

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

Client will have formed stools within 24 hours.

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client's orders, the nurse notes that one of the physicians wrote orders to ambulate the client, whereas another physician ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?

Communicate with the physicians to coordinate their orders.

Recording prioritized outcomes in the plan of care ensures which benefit?

Continuity of care can be provided to the client.

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client's friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do?

Delay the instruction until the visitors leave.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which?

Finances of the client

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records?

Impaired Physical Mobility related to pain

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which nursing diagnosis would be correct?

Ineffective Airway Clearance related to thick mucus

Which statement regarding critical thinking in nursing is true?

It is a systematic way of thinking.

What association meets every 2 years to further progress in defining, classifying, and describing nursing diagnoses?

NANDA-International (NANDA-I)

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

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." Which nursing action is the priority?

Resolve the client's anxiety.

After completing a client abdominal assessment, the nurse finds diminished bowel sounds. To determine what intervention is needed, which step would the nurse take first?

Review the client's recent food and fluid intake.

Which is an example of a long-term outcome for a client with asthma?

The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.

Which of the following reflects the diagnosis phase?

The nurse identifies that the client does not tolerate activity.

A new mother is having difficulty breastfeeding a newborn. A goal was established stating that the infant would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding 4 days ago. The nurse evaluates the original goal as:

completely unmet.