Foundations Exam 2

A nurse is administering a piggyback infusion to a client with second-degree burns. Which of the following describes the most important feature of a piggyback infusion?

A parenteral drug is given in tandem with IV solution In a piggyback infusion, a parenteral drug is administered in tandem with a primary IV solution. Medication locks are not changed during piggyback infusion specifically, but in general to maintain patency. IV medication or fluid is given all at one time as quickly as possible in a bolus administration, not in piggyback infusion. It is not the primary IV solution but the secondary infusions that are administered by gravity in tandem with the currently infused primary solution.

To which of the following patients would the nurse be most likely to administer a PRN medication?

A patient who is complaining of pain near her surgical site A complaint of "breakthrough" pain, especially postsurgery, would likely require the nurse to administer a PRN analgesic. A new onset of chest pain would likely require a stat order, while longstanding treatment of hypertension and asthma would likely include standing orders for relevant medications.

A nurse is preparing to insert an I.V. catheter into the skin. The nurse prepares to enter the skin a which angle?

25 degrees When inserting the IV catheter, the nurse enters the skin at a 15- to 30-degree angle and then as the skin is pierced, the nurse decreases the angle to 15 degrees. Doing so permits entry into the veins at an angle and decreases the risk of puncturing through a vein.

A nurse is preparing to administer a subcutaneous injection of heparin. Which size needle would be most appropriate to use?

28-gauge For subcutaneous injections, a 26- to 30-gauge needle should be used. Sizes, such as 18-gauge, 21-gauge, and 24-gauge needle would be inappropriate.

Which of the following data entries follows the recommended guidelines for documenting data?

"Following oxygen administration, vital signs returned to baseline." 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.

The following information appears on a client's medical record: Client states, "I have a fair amount of pain in my belly near my incision"; heart rate 88; respirations 22; abdomen distended; incision clean and dry; last medicated for pain 5 hours ago; abdominal pain secondary to surgery 2 days ago; reassess pain level using pain rating scale in 30 minutes; administer oxycodone 5 mg as ordered; monitor vital signs every 4 hours; client lying on side with legs drawn up and massaging abdominal area. When documenting this information using the SOAP method, which of the following would the nurse document as "S"?

"I have a fair amount of pain in my belly near my incision" When using SOAP notes, the client's statement would be documented as "S". Administration of oxycodone would be documented as "P". The client's position (lying on his side with legs drawn up) and abdominal distention would be documented as "O".

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?

"I think fatigue is a problem for you. Do you agree?" 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.

After teaching a group of nursing students about the medical record and its purposes, the instructor determines that the group needs additional instruction when the students state which of the following?

"Medical records are primarily used for communication among nurses and physicians." Medical records provide a means of communication for all healthcare team members involved in the client's care, not just nurses and physicians. The medical record is a valuable source of information about assessment data; documentation in the medical record provides the basis for decisions regarding care and subsequent reimbursement. Studying client records is often used for conducting research.

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?

"Unable to palpate femoral pulse in left leg." 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.

An adult with diabetes receives 20 units of insulin each morning and evening. How will the nurse teach the patient to administer the insulin?

"Use an insulin syringe and give 20 units." Insulin doses are calculated in units. The scale commonly used is U100, based on 100 units of insulin contained in 1 mL of solution. The adult patient is taught to measure by units, not mL.

The expected outcome for a client with a new diagnosis of diabetes mellitus (DM) is: client will describe appropriate actions when implementing the prescribed medication routine. Which statement by the client indicates the outcome expectation has been met?

-"I will test my glucose level before meals and use sliding scale insulin." The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration and storage, and conditions that require contact with the healthcare provider.

Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?

-"Assessment data about the client should be collected continuously." Data about the client are collected continuously because the client's health status can change quickly.

The nurse is interviewing a client who was admitted to the acute care facility. During the interview, the client states, "Sometimes I get a bit fuzzy after I take my medicine." Which response by the nurse would be most appropriate?

-"Can you tell me what you mean when you say 'fuzzy'?" The most appropriate response would be to clarify what the client means by 'fuzzy'. This response indicates that the nurse was actively listening to and hearing what the client had said. Telling the client that his complaint is not unusual ignores what the client has said and blocks communication. Asking if the client is experiencing lightheadedness shifts the focus of the interview to the nurse and the nurse's interpretation, rather than to what the client is reporting. Asking the client about the medications being taken changes the subject and is inappropriate.

How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation?

-"Client states, 'I don't see the point in trying anymore.'" Subjective data should be recorded using the client's own words, using quotation marks as appropriate. Paraphrasing the client's words may lead to assumptions and misrepresentation

How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation?

-"Client states, 'I don't see the point in trying anymore.'" Subjective data should be recorded using the client's own words, using quotation marks as appropriate. Paraphrasing the client's words may lead to assumptions and misrepresentations.

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?

-"Do you take anything to help your constipation?" 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.

Which of the following entries would be an example of appropriate documentation?

-"I am so down today, and I just don't have any energy." Subjective data should be recorded in the patient's own words, and quotation marks should be used. Avoid using nonspecific terms such as good, average, large, and small. Do not make judgments or inferences.

After conducting the initial assessment of a new resident of a long-term care facility, the nurse is preparing to terminate the interview. Which of the following questions is the most appropriate conclusion to the interview?

-"Is there anything else we should know in order to care for you better?" A helpful strategy in the termination phase of an interview is to ask the client: "Is there anything else you would like us to know that will help us plan your care?" This gives the client an opportunity to add data the nurse did not think to include. Expectations and previous practices should be addressed during the working phase of an interview.

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?

-"Mr. Koeppe, tell me what you do to take care of yourself." 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.

An 84-year-old male has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease (COPD) and elevated blood glucose. Which statement by the client could help identify the most likely reason for the changes in his health status?

-"My wife's been gone for about seven months now." The client's loss may be affecting how he is able to provide self-care. Emotionally, he may be depressed and questioning the benefits of his health care regimen, or he may have depended on his wife to help with his health care and not have the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet his needs. The statements concerning having a family member staying with him, having help with the yard work and sorting medications into an organizer should be explored, but do not reflect the same emotional impact in the client's life as the loss of a spouse.

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." In the planning stage of the nursing process the nurse must focus on the client's interests and preferences, keep an open mind, and include interventions that are supported by research. While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client's choices must be included in the plan for it to be successful. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care.

Which question or statement would be appropriate in eliciting further information when conducting a health history interview?

-"Tell me more about what caused your pain." 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 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?

-"Unable to palpate femoral pulse in left leg." 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.

A nurse is conducting an interview with a patient who complains of abdominal distress. What is an appropriate interview question for this patient?

-"What is your problem as you see it?" Asking the question, "What is your problem as you see it?" is an exploratory and open-ended statement that encourages the patient to provide his or her own feelings and interpretation of the current problem. Asking the client if they have eaten something that could have been spoiled or asking if they may have appendicitis are leading questions that block the patient's own feelings and response. Asking the patient if they are "feeling poorly besides your stomachache" may be misinterpreting what the client is feeling and disregards the current complaint.

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques?

-"When did you first notice the rash on your leg?" An example of appropriate communication is the statement, "When did you first notice the rash on your leg?" This is an example of a direct question that can be asked to validate information or clarify information. The other sentences demonstrate poor communication techniques. The nurse should avoid cliches, questions that require a "yes" or "no" answer, intimidating "why" and "how" questions, probing questions, and using judgmental comments.

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

-"ineffective airway clearance related to thick mucus" 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.

A nurse is arranging for home care for patients and reviews the Medicare reimbursement requirements. Which patient meets one of these requirements?

-A patient who is homebound and needs skilled nursing care Home care Medicare reimbursement requirements would necessitate the client meet the following qualifications: the client is homebound and still needs skilled nursing care, rehabilitation potential is good (or the client is dying), the client's status is not stabilized, and the client is making progress in expected outcomes of care.

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

-A standardized care plan Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem.

Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry?

-A. Jones, RN

A patient accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence?

-Accurately documenting patient care on the patient record The client record is the only permanent legal document that details the nurse's interactions with the client and is the nurse's best defense if a client or client surrogate alleges nursing negligence. As the question is written, the only answer that addresses the situation is accurate documentation of the event in the client's record. Notifying the nursing team of the client's condition is important, but not the correct answer for the question. Client data should be correctly documented on the flow sheet, but again this is not the most correct answer to the question. The medication record should be accurate, but again not the best answer.

A student nurse is practicing to develop critical thinking skills specifically in the area of theoretical knowledge. With which activity would the student most likely be involved?

-Active reading The nurse can develop theoretical knowledge by active reading, studying, and writing. Experimenting in a lab improves technical skills. Working in a hospital improves both interpersonal as well as technical skills. Interpersonal skills can be gained through group work.

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type?

-Actual "Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual diagnosis because it describes a human response to a health problem that is being manifested. A wellness diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A possible nursing diagnosis is made when not enough evidence supports the presence of the problem, but the nurse concludes that it is highly probable and wants to collect more information.

Which of the following patient situations most likely warrants a time-lapsed nursing assessment?

-An elderly resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. A time-lapsed assessment is often indicated in the care of a stable patient whose current status is being compared to earlier baseline data. Shortness of breath and chest pain necessitate an emergency assessment, while a new admission to a unit or institution requires an initial assessment. Following up a known health problem most often requires a focused assessment.

A nurse is caring for an older adult client who is scheduled for a cystoscopy the next day to determine the cause of an overdistended bladder. The client informs the nurse that this the first time that she has been admitted to a health care facility for an illness. Which of the following is a diagnostic label the nurse would use to formulate the nursing diagnosis?

-Anxiety Anxiety is an accurate diagnostic label, the name of the nursing diagnosis as listed in the taxonomy. Compromised is a descriptor; physical immobility is a risk factor; overdistension is a related factor.

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response?

-Apply pressure to the surgical site to decrease bleeding. It is essential that the nurse be prepared to address life-threatening needs of the client. Excessive bleeding is a life-threatening issue. Determining the cause of the client's bleeding, assessing the vital signs, and notifying the health care provider are important, but the life-threatening issue must be addressed first.

A student takes an adult patient's pulse and counts 20 beats/min. Knowing this is not the normal range for an adult pulse, what should the student do next?

-Ask the instructor or a staff nurse to take the pulse. Because verification of all data is neither possible nor necessary, nurses need to decide which items need to be verified. Data need to be verified when there are discrepancies to be sure assessments and documentation are accurate.

During the nursing examination, the nurse notices that the patient, an elderly female, becomes very tired, but there are still questions that need to be addressed in order to have data for planning care. Which action would be most appropriate in this situation?

-Ask the patient if it is okay to interview her husband for the answers to the interview questions. The nurse is responsible for collecting data in a timely manner. If the patient is too fatigued the nurse must ask for permission to obtain answers to interview questions from the husband prior to continuing to do so. Asking the patient to wake up is disregarding the patient's needs. Waiting until the following day is too long for the collection of important data.

The nurse is interviewing a client with complaints of chills, fever, malaise, and cough. During the working phase of the client interview, the nurse:

-Asks the client to describe symptoms. During the working phase, the nurse collects assessment data from the client. In the preparatory phase, the nurse prepares the environment for the interview. Introductions initiate the interview during the introductory phase. The nurse highlights key points of the interview in preparation for terminating the interview in the termination phase.

A nurse takes the vital signs of a new hospital patient admitted for severe abdominal pain. What initial step of the nursing process is this nurse performing?

-Assessment The assessment phase of the nursing process is the data collection phase, which includes establishing a data base through a physical assessment. Measuring vital signs is an example of establishing a data base through physical assessment. Diagnosis refers to the second step in the nursing process during which identification of patient problems occurs. Implementation involves the actual performing of planned nursing interventions. Evaluation involves determining if established patient goals have been met.

Then nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process?

-Assessment The nursing process is a systematic method used by the nurse and client. Assessment is the first step to determine the needs for client care.

A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify?

-Bathing self-care deficit related to lack of access to bathing facilities as evidenced by a strong body odor The most appropriate diagnosis would be "Bathing self-care deficit. The client is homeless and would not be able to access bathroom facilities. Homelessness has not been identified as a syndrome and there is only evidence of one problem. Inadequate hygiene has not been identified as a nursing diagnosis; furthermore, the word "stink" is an offensive term which must be avoided in nursing documentation. There is no evidence to suggest that the client has any issues with impulse control.

During the initial assessment of a newly admitted client, the nurse has clustered the client's range of motion (ROM) with his gait, his bowel sounds with his usual elimination pattern, and his chest sounds with his respiratory rate. The nurse is most likely organizing assessment data according to which of the following?

-Body systems The categorization of assessment findings according to systems (in this case, musculoskeletal, gastrointestinal, and respiratory) is characteristic of a body systems model for organizing data. While systematic, this strategy tends to ignore spiritual and psychosocial considerations.

Which of the following activities is the clearest example of the evaluation step in the nursing process?

-Checking the client's blood pressure 30 minutes after administering the captopril Measuring the client's blood pressure after performing an intervention such as drug administration determines the extent to which the client has achieved the outcome desired, which in this case is lowered blood pressure. Initially checking the client's blood pressure is an example of assessment, while recognizing it as an anomaly constitutes diagnosis. Administering the drug is a form of implementation.

A client reports to a health care facility with complaints of abdominal pain and vomiting. The client's wife informs the nurse that the client had gone out for dinner the previous night. Which of the following would be the primary source of assessment data?

-Client himself As the client is in a conscious state, he himself is the primary source of information since he can give firsthand information. The client's wife, friends, and test results would be secondary sources of data.

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?

-Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. 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.

Which is an appropriate expected outcome for a client?

-Client will ambulate safely with walker in the room within three days of physical therapy. Outcomes should be specific, measurable, attainable, realistic, and timebound. Safe ambulation after several days with physical therapy is a specific and reasonably attainable goal. Common errors to avoid when writing outcomes are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, using verbs that are not observable, and using verbs that are not measurable such as "know" and "understand".

The nurse caring for a client diagnosed with melanoma has identified a nursing diagnosis of "Ineffective coping." What subjective assessment data would provide evidence for this nursing diagnosis?

-Client's report of increased consumption of alcohol The client's increased consumption of alcohol is an unhealthy coping mechanism. The client's other statements indicate healthy ways of dealing with the illness.

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?

-Client's wife 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.

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?

-Cognitive Skill 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.

Of the following data, what type would be collected during a physical assessment?

-Color, moisture, and temperature of the skin Physical assessment is the examination of the patient for objective data that may better define the patient's condition and help the nurse in planning care. Physical assessment includes the color, moisture, and temperature of the skin. The health history interview would elicit information (data) about pain, nausea, and allergies.

A client with congestive heart failure has dyspnea while ambulating to the bathroom. The nurse selects the nursing diagnosis of "Activity intolerance" to address this health problem. Which of the following would be appropriate to select as the etiology of this nursing diagnosis?

-Compromised oxygen transport The pathophysiology of congestive heart failure decreases the body's ability to transport oxygen through the body. There is no evidence of client's unwillingness to ambulate. Cardiac disease is a medical diagnosis. Shortness of breath is the evidence that leads to the diagnosis of "Activity intolerance."

Which of the following best defines nursing diagnoses?

-Identification of client problems that nurses can treat independently Nursing diagnoses are written to describe client problems that nurses can treat independently. Medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Collaborative problems require that a nurse work with other health care professionals, and the treatment comes from nursing, medicine, and other disciplines. Nursing diagnoses identify actual and potential client problems.

A nurse in the emergency room, who is unfamiliar with pediatric clients, assesses the vital signs of a one month old infant with a heart rate of 124 and a respiratory rate of 36. What would be the most appropriate measure for the nurse to take to analyze the significance of the infant's vital signs?

-Consult reference materials to determine the normal vital signs for one month old infants. It is part of nursing practice to interpret the significance of assessment data by comparing it to standards. The nurse should consult reference materials to determine the normal range of vital signs for this client. Deferring to the emergency room is unprofessional and may result in harm to the client. Asking the mother if the infant's vital signs are higher than normal is unprofessional practice. A complete physical assessment is not necessary a this time.

A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action?

-Consult with a more experienced nurse. A newly graduated nurse does not have the experience to interpret all data. The nurse must recognize when a consult with a more experienced nurse is needed. There is no evidence that the nurse needs to collect more data. The data must be documented, but if the data is significant, it may harm the client if no action is taken. There is no need to contact the health care provider at this time.

The nursing process provides a framework for the patient and nurse to work together. Recording prioritized outcomes in the plan of care ensures which benefit?

-Continuity of care can be provided to the patient. When outcomes are recorded and prioritized, each nurse can quickly determine priorities of care and the patient benefits from continuity of care. The nurse may not pick and choose which priorities to accomplish; the plan does not ensure the patient will reach the goals, and the plan of care is more than the patient's "wants".

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?

-Diagnosing After assessing the need for nursing care, the nurse clearly identifies client strengths, and actual and potential problems in diagnoses.

Which step of the nursing process involves reporting or analysis of data to identify and define health problems?

-Diagnosis During the second phase of the nursing process, nursing diagnosis, the nurse reports or analyzes data to identify and define health problems that independent or physician-prescribed nursing actions can prevent or solve. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care, performing interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments.

A client tells the nurse, "My doctor has told me I have to have a blood transfusion, but I am a Jehovah's Witness and I can't take one." What is the nurse's most appropriate intervention?

-Discuss possible alternatives to a blood transfusion with the physician. As coordinator of the client's care, the nurse functions as an intermediary between the physician and the client. In order to honor the client's wishes, the nurse would most appropriately consult with the physician to meet the client's physical needs, as well as the client's spiritual needs. The risk and benefits of a blood transfusion are not the relevant issue with the client. Discussing the client's options with other church members would violate the client's privacy and would not meet the client's physical needs. It might be advisable to discuss the client's refusal of care with the hospital risk manager to protect the legal requirements of the institution, but it is not the priority.

Which of the following is an important element of implementation?

-Documentation An important element of implementation is documentation. The client database includes all the information that is obtained from the medical and nursing history. Physical examination and diagnostic studies are not an important element of implementation. Critical thinking is intentional, contemplative, and outcome-directed thinking. Developing good critical thinking skills will make nurses more efficient and effective at resolving situations requiring multiple interventions. Nursing orders are specific nursing directions so that all healthcare team members understand what to do for the client and, therefore, are not an important element of implementation.

A client who is bleeding profusely from a stab wound is brought to the emergency department. Which of the following types of assessment is most appropriate for this client?

-Emergency An emergency assessment is used to identify life-threatening problems and done when a physiologic or psychological crisis presents. It is different from a focused assessment, which is used to gather information about a particular problem.

A hospital patient has an aggressive fungal infection in his right eye that has necessitated evisceration (removal of the eye). Consequently, the patient requires twice-daily packing and dressing changes to his orbit. Which of the nurse's following actions in the care of this patient most clearly demonstrates interpersonal skills?

-Ensuring the patient's privacy during dressing changes and providing an explanation during the procedure A central aspect of interpersonal skills is maintaining privacy and dignity, as well as keeping patients informed during their care. Documentation is an outcome of legal/ethical skills while knowledge of anatomy and physiology demonstrates cognitive skill. The maintenance of asepsis involves technical skill.

Place the nursing activities in the order that they would most likely occur when a health care professional uses the nursing process:

-Establishing the database -Interpreting and analyzing patient data -Establishing priorities -Carrying out the plan of care -Measuring how well the patient has achieved desired outcomes -Modifying the plan of care (if indicated) A complete database must first be established in order to allow for interpretation and analysis of the patient data. Once problems or potential patient problems have been identified prioritization can occur in the form of establishment of goals/outcomes and planned nursing interventions. The plan can then be carried out, which leads to measuring if the patient achieved the desired outcomes. If outcomes were not met or partially met the plan of care can be modified.

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?

-Ethical/legal skills 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.

A nurse administers medications to a patient as part of the implementation step of the nursing care plan. What step of the nursing process would the nurse perform next?

-Evaluating The five systematic steps of the nursing process are assessment, diagnosing, planning, implementation, evaluation. Evaluation of patient goals follows implementation of nursing interventions. If interventions were effective, the patient goal has been met. Assessing is the first step in which data is collected. Diagnosing is the second step in which the patient problem, that the nurse is able to treat, is identified. Planning occurs after identification of the nursing diagnoses.

What common problem is related to outcome identification and planning?

-Failing to involve the client in the planning process 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 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?

-Focused Assessment 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.

An older adult male with a history of benign prostatic hyperplasia presents to the emergency room with complaints of urinary retention. The nurse collects data related to the patient's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing?

-Focused Assessment The nurse is performing a focused assessment that involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the patient's health. An emergency assessment is performed to identify life-threatening problems. A time-lapsed assessment compares a patient's current status to baseline data obtained earlier.

Which type of assessment would the nurse be expected to perform on the client who is one day post-op following a cholecystectomy?

-Focused assessment The nurse conducts a focused assessment of the client with a specific identified problem. An initial assessment is conducted by the nurse to establish baseline database and identify current health problems. The nurse performs an emergency assessment during a crisis to identify life-threatening problems.

An older adult male with a history of benign prostatic hyperplasia presents to the emergency room with complaints of urinary retention. The nurse collects data related to the patient's voiding patterns, weight gain, fluid intake, urine volume in the bladder, and level of suprapubic discomfort. What type of assessment is the nurse performing?

-Focused assessment The nurse is performing a focused assessment that involves gathering data about a specific problem that has already been identified. An initial assessment involves the nurse collecting data concerning all aspects of the patient's health. An emergency assessment is performed to identify life-threatening problems. A time-lapsed assessment compares a patient's current status to baseline data obtained earlier.

A nurse has gathered data through interview, observation, and physical assessment of a client and has formulated diagnostic statements. Which of the following would the nurse do during the outcome identification phase?

-Formulate client-focused goals During the outcome identification stage, the nurse should formulate client-focused goals that are measurable and realistic. Analyzing assessment information and performing diagnostic validation are completed during the diagnosis phase. Establishing nursing interventions is completed during the planning phase. (less)

The nurse is aware that basic patient needs must be met before a patient can focus on higher ones. According to Maslow's hierarchy of human needs, which example would be the highest priority for a patient after physiologic needs have been met?

-Grab bars are installed in a patient bathroom to facilitate safe showering. According to Maslow, safety and security needs follow basic physiological needs; therefore, grab bars in a bathroom helps ensure safety in the patient's shower. Enrolling in an art class would meet love and belonging, self-esteem, or self-actualization needs. Arranging for a teenager to have friends visit would help in meeting love and belonging needs. Identifying strengths in a patient demonstrates self-esteem needs.

A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this patient?

-High Risk for Injury related to unsafe home environment The nursing diagnosis "High Risk for Injury related to unsafe home environment" is appropriate because it contains the NANDA-I nursing diagnosis problem statement and the etiology of the problem. High Risk for injury related to abusive parents is accusatory and may not be accurate. High risk for injury related to impaired home management does not accurately identify the etiology of the problem. Child abuse is not a NANDA-I approved nursing diagnosis.

A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem?

-Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis The client is expressing a lack of hope for the future which makes "Hopelessness" an appropriate nursing diagnosis. There is no evidence that the client has a disturbed self concept. There is no evidence that the client is not effectively caring for health. The client does not verbalize a desire to learn about treatment options.

A nurse is interviewing an elderly client who has experienced a drastic weight loss following a CVA (cerebrovascular accident). The client states, "I have trouble getting groceries since I can no longer drive, so I don't have much food in the house." Based on this evidence, what would be the most appropriate nursing diagnosis?

-Imbalanced nutrition: less than body requirements related to difficulty in procuring food The client's relates the drastic weight loss to the inability to bring food into the house. The client's statement is the most appropriate etiology for the nursing diagnosis. Drastic weight loss is the evidence of imbalanced nutrition. Cerebrovascular accident is the medical diagnosis. The client could have had a CVA and still have the ability to grocery shop. There is no evidence that the client has lost appetite.

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

-Impaired physical mobility related to pain "Impaired physical mobility related to pain" is the correct nursing diagnosis because it consists of an accurate descriptor, diagnostic label, and related factor. "Ineffective movement related to arthritis" is an incorrect entry because the descriptor is incorrect and the diagnostic label is not approved. "Impaired movement due to pain" is an inaccurate entry because the descriptor is inaccurate and the related factor is not written using approved words. "Ineffective physical mobility due to pain" has an erroneous diagnostic label and the related factors are written incorrectly.

A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care?

-Include the client and the client's power of attorney in the discussion. During the planning step of the nursing process the nurse develops and prioritizes an individualized plan of care in partnership with the client, family, and others as appropriate. The client with mental or physical limitations should be included in the plan as much as possible. When there are cognitive limits, the client's power of attorney (POA) should also be included in the plans.

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?

-Ineffective airway clearance as evidenced by inability to clear secretions 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 dyspnea" is incorrectly written because the "related to" statement essentially restates the nursing diagnosis. "Ineffective therapeutic regimen management due to smoking" is incorrect because the clause "due to" implies a direct cause-and-effect relationship.

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem?

-Ineffective health maintenance related to client's denial of illness The most appropriate diagnosis is ineffective health maintenance related to client's denial of illness. The data presented in the question stem point to the fact that the client is not managing the diabetes because the client is denying that it is a problem at all. The client is at risk for unstable blood glucose, but the client's denial is the underlying problem. Risk for injury relates to safety issues. It is also inappropriate documentation to say the client is "mismanaging" the illness. Ineffective coping could be an appropriate diagnosis, but the client is not "unable" to manage the illness, just unwilling.

The nurse is caring for a client with AIDS (acquired immune deficiency syndrome) who frequently misses clinic appointments. The client states that transportation to the clinic is very difficult. What would be the nurse's most appropriate diagnosis?

-Ineffective health maintenance related to transportation difficulties Ineffective health maintenance related to transportation difficulties is the correct answer. The client is having difficulty coming to clinic appointments necessary to monitor the progression of AIDS. The client states the cause of the missed appointments is transportation difficulties. The client does have AIDS, but that is not why the appointments are missed. The client is at risk for noncompliance with the prescribed therapy, but the actual diagnosis of "Ineffective health maintenance" is most appropriate to address the situation.

When charting the assessment of a client, the nurse writes,"Client is depressed." This documentation is an example of which of the following?

-Interpretation of data It is always best to describe behavior rather than to interpret behavior. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client. Stating that "client is depressed" is an interpretation of the client's behavior and not a factual statement.

A nurse is assessing a client admitted to the health care facility with angina. Which method would be most appropriate for the nurse to use to collect subjective data?

-Interview The nurse should interview the client to collect subjective data, which include the client's feelings and statements about his health problems. Objective data are collected through measuring devices and equipment, such as a stethoscope and scale, as well as laboratory studies. Objective data are known as signs and are observable, perceptible, and measurable.

Two nurses have disagreed about the role of intuition in nursing practice, with one nurse characterizing it as "hocus-pocus" and the other nurse advocating it as a superior problem-solving strategy. Which of the following statements best conveys the role of intuition in nurses' problem solving?

-Intuition can be a clinically useful adjunct to logical problem solving. Creative, intuitive thinking can be useful supplements to more "in-the-box" methods of problem solving. While it should not be discouraged outright, it should also not be thought of as a replacement for logical or scientific problem solving. Intuition is not dependent on a special gifting, but is thought to be a product of experience and unconscious pattern recognition.

When performing an assessment, the nurse should focus on the developmental stage for which of the following clients?

-Toddler Nursing assessments vary according to the client's developmental needs. When assessing an infant, toddler, or child, special attention is given to physiological and psychosocial aspects of growth and development to identify client problems. It is not as important to focus assessment on the developmental stages in the other age groups.

As the nurse bathes a patient, she notes his skin color and integrity, his ability to respond to simple directions, and his muscle tone. Which statement best explains why such continuing data collection is so important?

-It enables the nurse to revise the care plan appropriately. Continuous data collection ensures that the nurse has the most current patient data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed upon admission, but the patient's condition is always changing. The purpose of continued data collection is to provide good patient care; it does not related directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.

A nursing instructor is describing the nursing model of 'person-centred care' to a class. Which of the following would the instructor include as a characteristic of 'person-centred care'?

-It is a framework for providing care The model of 'person-centred care' is a framework for providing care. The approach is not independent of other disciplines, but is interdependent with other disciplines such as medicine, physiotherapy, surgery, etc. The model can be used in all settings and is not limited to hospital settings. 'Person-centred care' aims to provide specific care to people based on individual needs.

A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?

-Knowledge deficit: medications related to new medical diagnosis To most appropriately address the client's health problem, the client needs education about the new medications the physician as prescribed to treat a newly diagnosed case of asthma. Ineffective airway clearance refers to the physiological processes of asthma. There is no evidence of noncompliance. There is no indication that the client is having difficulty dealing with the diagnosis.

Your patient is admitted with multiple injuries, including a head injury, fractured ribs, and hypoventilation. Vital signs are: BP 110/84, T. 98.8, P. 88, Resp. 28. The nursing care priority is which of the following?

-Maintain an open airway A patent airway is always the priority of nursing care, particularly for patients with a head injury and hypoventilation.

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?

-Make recommendations for revising the plan of care. 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 documenting the effectiveness of a patient's pain management on the patient record. Which documentation is written correctly?

-Mr. Gray reports that on a scale of 1 to 10, the pain he is experiencing is a 3. The documentation that records the client's pain on a numeric scale is written correctly. Subjective words such as "sufficient", "appears comfortable", "resting adequately", and "appears to have a low tolerance for pain" should not be used in documentation of a client's pain management.

A nursing student is discussing assessment findings of an assigned client with the instructor. The instructor determines that the student needs additional assistance and review when the student identifies which as objective data?

-Nursing staff Nursing staff is a source of subjective data. Subjective data are collected from many sources such as the client, family members, or significant others. Data collected from health records, physical assessment, and measurement devices are objective data.

After performing the admission assessment on an older adult client, the nurse documents the following, "Client observed fidgeting with covers; facial grimacing when turning from side to side." This documentation is an example of which type of data?

-Objective Objective data is data that is observable and measurable data that can be seen, heard, felt, or measured by someone other than the client. Subjective data are information perceived only by the affected person. The others are not types of data.

A nurse is writing goals for a client who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this client?

-Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. Goals must be client-centered, specific, measurable, attainable, realistic, and timebound. "Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse" has all of these characteristics. "The nurse will help the client ambulate the length of the hallway once a day" is not specific in whether assistance is required and it is not time bound. "Offer to help the client walk the length of the hallway each day" is a nursing intervention. "The client will become mobile within a 24-hour period" is not specific or measurable.

While examining a client, the nurse assesses the temperature of the client's skin. The nurse most likely would be using which technique?

-Palpation Palpation is used to assess the temperature of the skin. Inspection would reveal color, shape, movement, pulsations, and texture of an involved body part. Percussion determines a structure's denseness or hollowness and aids in discovering the location and level of organs, consistency of body structures, the presence of tenderness, and identification of masses or tumors. Auscultation identifies normal and abnormal sounds (such as in the bowel, lungs, heart) as well as the sound of blood moving through a narrowed or twisted vessel.

A nurse is assessing a patient admitted to the hospital with complaints of left-sided weakness and difficulty speaking. Which assessment contains the data that best represent a nursing assessment?

-Patient is unable to communicate basic needs and cannot perform hygiene measures with left hand. The nursing physical assessment focuses primarily on the patient's functional abilities, which provides the nurse with the appraisal of the patient's health status, the identification of health problems, and the establishment of a database for nursing interventions. Identifying that the patient is unable to communicate basic needs and perform hygiene measures with the left hand demonstrates this concept. The purpose of the physician's physical assessment is to identify pathologic conditions and their causes. The interpretation of the neurologic examination and the brain scan, and the probability of the cause being a stroke are part of the physician's physical assessment.

A nurse formulates a plan of care for a client who has experienced a stroke. Which of the following would the nurse do to establish accurate nursing diagnoses for this client?

-Perform cluster interpretation The nursing diagnostic process uses cue clustering, cluster interpretation, and diagnostic validation to ensure accuracy in selecting the correct diagnoses. Identifying intervention strategies, performing reassessment, and evaluating the client's response are inappropriate activities to ensure accuracy of nursing diagnoses. Identifying intervention strategies is an activity performed when preparing the care plan for the client once the diagnoses and outcomes have been identified. Reassessment and evaluation of the client's response are carried out in the implementation phase of the nursing process.

A nurse is performing a head-to-toe examination of a child. Which action would be most important for the nurse do?

-Perform invasive techniques at the end of the exam When using the head-to-toe approach with a child, it is important that invasive techniques are done last. Vital signs are usually obtained before the physical exam begins. Assessing the child's neurologic status would be done when using a body systems model, not a head-to-toe model. Although the parents are valuable sources of information, the nurse should not rely solely on this information for the child's general state of health. The nurse would assess the child's state of health at the beginning of the head-to-toe examination.

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?

-Planning 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.

The nurse has measured from the tip of the client's nose to his earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which of the following components of the nursing process has the nurse demonstrated?

-Planning; implementing Determining the correct length of the NG tube to insert is an example of the planning that is necessary in order to conduct this nursing action. The actual insertion of the NG tube would constitute an implementation. (less)

As a beginning student in nursing, what is essential to the mastery of technical skills, such as giving an injection?

-Practice giving injections in the learning laboratory until you feel comfortable. 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.

Which of the following interpersonal skills is essential to the practice of nursing?

-Promoting the dignity and respect of patients as people 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.

A nurse has identified on the plan of care for a client a nursing diagnosis of "anxiety related to concerns about cancer treatment as evidenced by client's statement." One of the interventions that the nurse writes on the plan of care is to encourage the client to verbalize his feelings about the diagnosis and its effect on his quality of life. The nurse has identified which type of nursing intervention?

-Psychosocial The nurse has identified a psychosocial intervention, which focuses on supporting, exploring, and encouraging. Psychomotor interventions involve actions such as positioning, inserting, or applying. Sociocultural interventions involve spending time and incorporating cultural differences into the care regimen. Educational interventions involve demonstrating, education, and observing return demonstrations.

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?

-Record an evaluative statement in the client's plan of care. 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.

In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged?

-Reevaluating Experience in light of ideas Reflection at the higher level includes reevaluating experience in the light of ideas, behavior, feelings, and values. Reflection at the basic level includes recalling the sequence of events, identifying a positive situation, and thinking about relationships involved.

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?

-Reflective Practice 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.

A patient is to receive intravenous (IV) fluid therapy and the nurse is preparing the solution for use. Place the following steps in the order in which the nurse would perform them.

-Remove the IV solution bag from the outer plastic covering. -Close the flow clamp on the IV administration set. -Remove the protective cap from the tubing insertion port and spike on administration tubing. -Insert the spike of the administration set into the port on the IV solution bag. -Invert the IV solution bag and hang it on the IV pole. -Compress the drip chamber until it is approximately one-half full.

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which of the following is the best example of establishing a therapeutic nurse-client relationship?

-Respect for the client, and engaging in open communication in getting to know the client. Answer A is the best response: Respect for the client's dignity, and establishing a caring relationship is furthered by mutual interchange of communication. Approaching care/client as a job, doing things without client input, and doing things your way and efficiently are not necessarily therapeutic nor do they initiate communication.

A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern?

-Risk for community contamination related to possible environmental pollution The nurse has identified a risk diagnosis because of the unknown health effects of the chemical plant on the community. Risk for community contamination would address the broad concerns of the nurse. Knowledge deficit is not appropriate because it has too narrow a focus. Deficient community health is not a NANDA diagnosis and the etiology must deal with how the plant may possibly affect the community. Risk for infection has a very narrow focus. The etiology of community contamination has not been proven.

Which of the following statements is true of the nursing process?

-Scientific problem solving can occur within the nursing process. Problem solving and the nursing process are not competing or mutually exclusive processes. Rather, both scientific problem solving and trial-and-error may take place within the nursing process. One of the strengths of the nursing process is that it is applicable to all nursing contexts.

After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnoses for a client. For what are the nursing diagnoses used?

-Selecting nursing interventions to meet expected outcomes 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 nursing instructor is teaching the students how to do an interview on a client. Which of the following statements made by a student indicates a need for further instruction?

-Show your name badge to the client so they can read who you are When conducting an interview the nurse should sit at eye level and introduce themselves and tell their position. This sends the message that the nurse accepts responsibility and are willing to be accountable.Verify the client's name and ask what they would like to be called. Some clients cannot read and they should not be expected to know your name and your position by reading a name badge.

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?

-Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing 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.

A group of student nurses are working on developing various nursing skills and are at various stages of skill acquisition. The instructor determines that which student is at the novice stage?

-Student used rules to guide practice During the novice stage of skill acquisition, the learner uses rules to guide practice. The learner considers more facts and rules during the advanced beginner stage. At the competence stage, the learner feels responsible for outcomes. The learner knows the goal and how to achieve it at the expert stage.

A group of student nurses are working on developing various nursing skills and are at various stages of skill acquisition. The instructor determines that which student is at the novice stage?

-Student uses rules to guide practice During the novice stage of skill acquisition, the learner uses rules to guide practice. The learner considers more facts and rules during the advanced beginner stage. At the competence stage, the learner feels responsible for outcomes. The learner knows the goal and how to achieve it at the expert stage.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss?

-Subjective data should be included when documenting Subjective data should be included when using the SOAP format for documentation. Objective data is what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SAP note is more about the health care providers' judgment about the situation, and abnormal lab values would be included in objective data.

After developing the plan of care for a client, the nurse implements that plan. Which of the following would the nurse most likely use?

-Technical Skills During the implementation phase, intellectual, interpersonal and technical skills are used. Awareness of clinical research and knowledge of care standards are important aspects of the planning and the evaluation phase of the nursing process. Observation is an important requirement in the assessment phase for collecting data.

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

-The North American Nursing Diagnosis Association (NANDA) North American Nursing Diagnosis Association (NANDA) conferences are held every 2 years, and much progress continues to be made in defining, classifying, and describing nursing diagnoses.

Which nurse is using criteria to determine expected standards of performance?

-The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. Standards are the levels of performance accepted and expected by the nursing staff and other health team members, such as institutional policies and procedures. The nurse preceptor providing feedback to the new graduate nurse after six weeks of orientation is an example of peer review. The nurse manager providing the staff nurse feedback regarding job performance for the previous year is typical of an annual employee review.

The nurse is caring for a client who has been diagnosed with a sexually transmitted infection (STI). The nurse plans to address the nursing diagnosis of "Risk prone behavior." What assumption has the nurse made?

-The nurse has assumed that having a sexually transmitted infection means the client is sexually promiscuous. Risk prone behavior identifies habits of the client that are dangerous. Being sexually promiscuous would be a dangerous behavior. Risk prone behavior does not mean that the client is not knowledgeable or needs further instructions about complications.

The nurse has identified the following outcome for the client: The client will have a soft formed stool. Which error has the nurse made in writing the outcome?

-The nurse has omitted the time frame. Outcomes are client-centered, use action verbs, identify measurable criteria, and include a time frame as to when the outcome should be achieved. The time frame has been omitted.

The nurse has selected a nursing diagnosis of "Impaired home maintenance" for an elderly client. What assessment data would evidence this diagnosis?

-The nurse observes unsafe conditions in the client's home. The observation of unsafe conditions indicates that the client is not effectively maintaining the home. The client's confusion may be a temporary condition and does not take into account any help the client has in maintaining the home. Living with family members provides a source of support for the client which should assist in home maintenance. The client's distaste for housework does not mean that the client is not maintaining the home.

During morning report, the night nurse tells the day nurse that the client refused to allow the technician to draw blood for laboratory testing. What step would be essential for the day nurse to complete before selecting a nursing diagnosis to address this issue?

-The nurse should determine the client's reason for the client's refusal. Before addressing the issue, the nurse must determine why the client refused the lab draw. It is essential to know the cause before planning how to address the issue. It is immaterial how long the client has been in the hospital, what laboratory tests are critical, or what the client's last results were.

The nurse is performing a physical assessment of a client admitted with emphysema. How will the nursing physical assessment differ from a medical physical assessment?

-The nurse's physical assessment will focus on the client's functional abilities. Unlike the physical assessment performed by the physician to identify pathologic conditions and their causes, the nursing physical assessment focuses primarily on the client's functional abilities.

The nursing instructor is teaching the students how to do an interview on a client. Which of the following statements made by a student indicates a need for further instruction?

-The nursing instructor is teaching the students how to do an interview on a client. Which of the following statements made by a student indicates a need for further instruction? When conducting an interview the nurse should sit at eye level and introduce themselves and tell their position. This sends the message that the nurse accepts responsibility and are willing to be accountable.Verify the client's name and ask what they would like to be called. Some clients cannot read and they should not be expected to know your name and your position by reading a name badge.

During a home health care visit, the nurse identifies a nursing diagnosis of "Caregiver role strain" for a parent who is caring for a ventilator dependent child. What subjective assessment data would support the nurse's diagnosis?

-The parent states, "I cannot allow anyone else to help because they won't do it right." The parent's statement of not allowing anyone to help because "they won't do it right" is the correct answer. The parent's statement indicates an inability to allow help, which will cause mental and physical strain. The other statements are statements of a healthy ability to use coping mechanisms to deal with this difficult situation.

Nurses collect objective and subjective data when performing patient assessments. What is an example of objective data?

-The skin of a patient who has liver failure has a yellowish tint. Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same patient. Complaints of nausea, feeling very anxious, and complaints of dizziness are subjective data. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person.

A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which of the following people would be entitled to access of the client's records?

-Those directly involved in the client's care Only those directly involved in client care are entitled to access the client's information. Family members and close friends do not have access to the client's records, as per the privacy policy of the client. Health care professionals of the health care facility cannot access client information unless involved in client care.

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?

-Time Lapsed 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.

A nurse working in an outpatient surgery center is responsible for taking a health history and performing a physical assessment on each patient scheduled for surgery. Why is establishing this database so important for nursing care?

-To identify strengths and problems Without a complete and accurate database, it is impossible for the nurse to identify patient strengths and problems. Assessing and establishing a database is the first step in the ordered sequence of events in the nursing process. The care team's time is not the focus. This assessment is an opportunity for establishing rapport but this is not the primary purpose.

What is the primary purpose of validation as a part of assessment?

-To plan appropriate nursing care 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.

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?

-To provide quality care with nursing ability and knowledge 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.

Critical thinking is important in making an effective nursing judgment. Which technique would be most effective for the nursing student to adopt to improve classroom success?

-Turn errors into learning opportunities The nurse should turn errors into learning opportunities to improve classroom success. Improving reading and writing skills, building a glossary of new words, and practicing active listening helps to improve the basic skills used in listening, studying, and thinking. Asking for assistance is often beneficial and should not be avoided.

The nurse is performing a physical assessment of a newly admitted client. During the assessment the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client is there is any pain the answer is "no." What is the best thing for the nurse to do next?

-Validate the data Data needs to be validated when there are discrepancies such as the client saying there is no pain but the nonverbal behavior indicates that they are experiencing pain.

While doing an assessment, the nurse identifies questionable data. Which of the following should the nurse do first?

-Validate the questionable data Questionable data are verified (validated) as part of the assessment step of the nursing process. It is not necessary to inform the doctor or the client that the data are questionable but that it needs to be verified.

A nurse is performing auscultation during the physical examination of a client. The nurse most likely would be assessing:

-a bruit The nurse uses the auscultation technique to assess a bruit. A bruit is the sound of blood moving through a narrowed blood vessel. Auscultation helps to listen to body sounds with a stethoscope. Size of the thyroid, shape of the liver, and tenderness near the spine cannot be assessed by auscultation. Size of the thyroid and shape of the liver can be assessed by palpation. Tenderness near the spine can be assessed by percussion.

Which of the following is not appropriate in writing client-centered measurable outcomes?

-a flexible time frame 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 is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using:

-assessment skills 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 nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

-client is normal tensive A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for hypertension is to have the blood pressure return to the expected range of between 90/60 mm Hg and 120/80 mm Hg. The other options do not directly indicate successful control of hypertension.

The nurse makes a diagnostic error when the:

-client withholds information during the nursing assessment. Diagnostic errors occur when the database is incomplete. Subjective and objective data that cluster together and point to a specific health problem decrease the likelihood of diagnostic errors. The risk of making a diagnostic error decreases when the client's subjective and objective data are congruent.

Which of the following group of terms best defines assessing in the nursing process?

-collection, validation, communications of client data Assessing is the systematic and continuous collection, validation, and communication of client data to reflect how health functioning is enhanced by health promotion or compromised by illness and injury. The terms problem focused, time lapsed, and emergency based describe types of assessments. Assessments are nurse focused and help in establishing nursing goals; they also are used in designing a plan of care and implementing interventions. Those terms describe what assessments do rather than what assessments are.

While implementing the plan of care for a client, the nurse uses interpersonal skills. Which of the following would the nurse most likely use?

-communication Communication is a key interpersonal skill to carry out interventions. Decision making, problem solving and teaching are intellectual skills.

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?

-concept map care plan 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.

A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged to implement the new strategies for ambulation the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

-developing the plan without client input Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care.

A nurse working in a critical care unit has formulated the following nursing diagnoses for a client. Which nursing diagnosis most likely would be of the highest priority?

-impaired gas exchange Impaired gas exchange is a high-priority nursing diagnosis because it may be life threatening if proper interventions are not initiated. Fatigue, stress urinary incontinence, and impaired skin integrity are medium-priority nursing diagnoses because they could result in unhealthy consequences but are not life threatening.

A nurse who has been employed by the facility is scheduled for an evaluation by a group of nurses with similar education and experience. The nurse most likely is undergoing which of the following?

-individual peer review Individual peer review involves evaluation of the nurse's performance by other nurses in which the individual nurse is evaluated and judged by other nurses with similar education and experience. Nursing monitor is a type of peer review that involves a review of a client's care or records to evaluate whether established standards were met. A process evaluation focuses on the nurse's performance and whether the nursing care provided was appropriate and competent. Quality improvement is a mechanism for healthcare organizations to assess and improve care and to ensure that quality client care is provided and standards are upheld.

A plan of care for a patient with a low potassium level includes providing information about the effect of medications and dietary intake of foods high in potassium. How would a nurse measure achievement of an outcome for this plan?

-laboratory data

A client was admitted two days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?

-ongoing planning Ongoing planning is carried out by any nurse who interacts with the client, and the chief purpose is to keep the plan up to date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting. Outcome planning is not discussed in this chapter.

A nurse assesses the vital signs of a patient who is one day postsurgery in which a colostomy was performed. The nurse then uses the data to update the patient plan of care. What are these actions considered?

-ongoing planning Ongoing planning is carried out by any nurse who interacts with the patient. Its chief purpose is to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function. The nurse caring for the patient uses new data as they are collected and analyzed to make the plan more specific and accurate and, therefore, more effective.

Use of the nursing process in healthcare allows the nurse to address the needs of the client. The nursing process:

-provides a universally applicable framework for nursing activities. The nursing process can be used with all clients, sick or well, of all ages and in all settings. The nursing process was not developed in 1955 nor designed for use by students in their assignments. Critical pathways target desired outcomes for particular illnesses, procedures, or conditions.

Personal characteristics demonstrate that one has developed critical thinking. Characteristics of critical thinking include:

-self-aware, honest, persistent, and authentic The characteristics of critical thinking include: self-aware, genuine/authentic, effective communicator, curious/inquisitive, confident/resilient, honest, creative, proactive, persistent, and improvement oriented.

Which intervention does the nurse recognize as a collaborative intervention?

-teach the client how to walk with a three-point crutch gait 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.

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?

-the need to feel good about oneself 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.

The nurse is developing outcomes for the care plan of a patient admitted with Parkinson's disease. The nurse will derive the outcomes for this patient's care plan from:

-the problem statement of the nursing diagnosis. Outcomes are derived from the problem statement of the nursing diagnosis. Remember that the nursing process is based upon independent nursing actions.

A nurse is giving post-operative care to a client after knee arthroplasty. Which of the following is a possible short-term goal for this client?

-to ambulate the client to a bedside chair The short-term goal in this case is to help the client ambulate to the bedside chair. The other goals, like helping the client return to activities of daily life, to maintain a healthy and active lifestyle, and to prevent repeat surgery are long-term goals and may take weeks or months to achieve. On the other hand, short-term goals can be achieved in a day or a week.

A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse:

-uses broad, open statements to communicate with the client The nurse should use broad, open statements to facilitate communication during an interview. Full attention should be paid to the client; paying too much attention to note-taking will interfere with good communication. False reassurance must be avoided and the nurse may not agree with every statement the client makes.

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

-uses critical thinking to direct care for the individual patient. The nursing process requires blended skills and critical thinking. Critical thinkers think systematically about the nursing process and apply it for the individual patient. Communication is important but not sufficient to meet patient needs, and scientific problem solving is used in the laboratory setting, not nursing.

The physician orders 250 mg amoxicillin via intravenous (IV) piggyback to run over 30 minutes for a patient. The pharmacy supplies a 50-mL bag of IV solution containing the 250 mg amoxicillin. The nurse would set the infusion rate at how many drops per minute when using a microdrip administration set?

36 To calculate the drip rate, the nurse would first determine the volume to be infused over 1 minute. Then using the formula, the nurse would multiply the total volume by the drop factor to arrive at 36 gtts/minute.

A nurse is administering total parenteral nutrition (TPN) solution to a severely dehydrated client at the health care facility. Which nutrient would the nurse identify as a carbohydrate source?

50% dextrose solution The carbohydrate source is often a 50% dextrose solution. The proportion of each ingredient is individualized based on the client's clinical condition. Protein is provided as synthetic crystalline amino acids, not as carbohydrates. The client's caloric need is assessed carefully to provide the number of calories required to maintain an anabolic state. Electrolytes such as sodium and potassium, vitamins, and trace elements are added, based on laboratory assays. To supply all necessary nutrients, fat in the form of 10% or 20% lipid emulsion is often given with TPN.

A physician at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which of the following describes the mechanism of a metered-dose inhaler?

A canister containing medication that is released when the container is compressed A metered-dose-inhaler is a canister that contains medication under pressure; the aerosolized drug is released when the container is compressed. A turbo-inhaler is a propeller-driven device that spins and suspends a finely powdered medication. An aerosol results after a liquid drug is forced through a narrow channel using pressurized air or an inert gas.

A nurse needs to administer a subcutaneous heparin injection to a client. Which of the following injection sites is most suitable for heparin?

ABDOMEN The abdomen area is the preferred site for a subcutaneous heparin injection because of less pain intensity. The forearm, back, and upper chest are common sites for an intradermal injection, not a subcutaneous injection.

A nurse is reviewing information about prescribed drug in a drug handbook in preparation for administration to a client. When reading about the drug, the nurse identifies which name as the generic name?

Ampicillin sodium Ampicillin sodium is a generic name. Each drug has only one generic name, which is often simpler than the chemical name from which it was derived. Omnipen-N, Polycillin-N, and SK Ampicillin-N are trade names. The brand name, or trade name, is a registered name assigned by the manufacturer.

A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which of the following guidelines for needle selection might they discuss?

As the gauge number becomes larger, the size of the needle becomes smaller. The larger the gauge, the smaller the needle. The first number on a needle package is the gauge or diameter of the needle and the second number is the length in inches. When giving an injection, the viscosity of the medication directs the choice of gauge. The size of the syringe is directed by the amount of the medication to be given.

A nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear?

Ask the client to maintain the position for some time After instilling the prescribed number of drops in the client's ear, the nurse should ask the client to maintain the position briefly until the solution travels toward the eardrum. When instilling the medication in the client's ear, the nurse first manipulates the client's ear to straighten the auditory canal. Tilting the client's head away, the nurse then administers the prescribed number of drops of medication. The client remains in this position briefly as the solution travels toward the eardrum. The nurse then places a cotton ball loosely in the ear to absorb the excess medication. The nurse then waits for at least 15 minutes before administering the medication in the opposite ear if prescribed. Briefly postponing the application within the second ear avoids displacing the initially instilled medication when repositioning the client.

A nurse is using an IV port when administering medication to a client. Which of the following IV administrations has the greatest potential to cause life-threatening changes?

Bolus administration Because the entire dose is administered quickly, bolus administration has the greatest potential to cause life-threatening changes should a drug reaction occur. An electronic infusion device, continuous administration, and secondary administration do have the potential to cause life-threatening changes, but not to the same degree as a bolus administration because the rate at which medication is administered is not as fast as during a bolus.

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?

Charting by exception 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.

A nurse is providing care for a patient who has a history of dementia. Which of the following methods should the nurse use in order to determine the patient's identity prior to medication administration?

Check the patient's identification band. For all patients, the preferred method of confirming identity is to read the patient's identification band.

After teaching a group of nursing students about pharmacokinetics, the instructor determines that the teaching was successful when the students identify which of the following as the process by which the medication is delivered to the target cells and tissues?

Distribution The process by which the medication is delivered to the target cells and tissues is called distribution. Absorption is the process by which a medication enters the bloodstream. Synergism is a drug interaction that increases the drug effect. The process of chemically changing the drug in the body is called metabolism; it takes place mainly in the liver.

The nurse is preparing to administer a medication via a nasogastric tube. What guideline is appropriate for the nurse to follow when administering a drug via this route?

Flush the tube with water between each drug administered. Guidelines to consider when administering a drug via nasogastric tube include positioning the client with the head of the bed elevated, administering the medication at room temperature for the client's comfort, flushing the tube with water between each drug administered, and avoiding the use of suction for 20 to 30 minutes after the drug is administered.

A nurse is administering an intramuscular injection of a viscous medication using the appropriate-gauge needle. What does the nurse need to know about needle gauges?

Gauges range from 18 to 30, with 18 being the largest. The gauge is determined by the diameter of the needle and ranges from 18 to 30. As the diameter of the needle increases, the gauge number decreases (an 18-gauge needle is, therefore, larger than a 30-gauge needle). A viscous medication requires a larger-gauge needle for injection.

A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which of the following actions should the nurse perform to prevent gastric reflux?

Help the client into a Fowler's position. Assuming Fowler's position can help prevent gastric reflux when medications are administered through an enteral tube. The nurse checks the client's medical history for drug allergies to avoid potential complications. Adding diluted medication to the syringe as it becomes nearly empty prevents instilling air into the syringe. Administering the medication over several minutes has no effect on reflux.

A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next?

Individualize it to the specific client 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 client is receiving IV therapy with an isotonic solution. The nurse notes swelling and coolness at the site along with an absent blood return. Which of the following would the nurse suspect?

Infiltration When IV solutions, such as isotonic solutions, inadvertently leak into the subcutaneous tissues, it is called infiltration. If the solution or medication is a vesicant or highly irritating, then it is called extravasation. Phlebitis is an inflammation of the vascular endothelium characterized by pain, warmth, and redness at the site. An air embolism involves the entry of air into the client's circulatory system manifested by pain in the chest, shoulder, or back; dyspnea; hypotension; thready pulse; cyanosis; and eventually loss of consciousness.

A nurse is documenting client information using PIE charting. Which information would the nurse expect to document?

Intervention carried out 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 administering an injection to a client at a 15-degree angle. The client has a venous access port. Which of the following injections can be administered at this angle?

Intradermal When giving an intradermal injection, the nurse instills the medication shallowly at a 10- to 15-degree angle of entry. When the nurse administers a subcutaneous injection, the angle of entry is either 45 degrees or 90 degrees, whereas for intramuscular injections, the angle is 90 degrees. Intravenous injections are instilled into the veins of the client at an angle of around 15 degrees, but only if no venous access port is in place.

The Z-track technique is utilized during drug administration by which of the following routes?

Intramuscular The Z-track technique is used for intramuscular injections to prevent leakage of medication into the needle track, thus minimizing discomfort.

A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. Which of the following is a feature of a metered-dose inhaler?

It is a canister that contains pressurized medication. A meter-dose inhaler has a canister that contains medication under pressure. It is much more commonly used than the turbo-inhaler, which is a propeller-driven device that spins and suspends a finely powdered medication. A turbo-inhaler, not a meter-dose inhaler, has propellers that get activated during inhalation.

A nurse at a health care facility has to instill ear drops in a client. The nurse knows that which of the following techniques varies for an adult and child client?

Manipulation of the client's ear to straighten the auditory canal The nurse should be aware that the method of manipulation of the client's ear to straighten the auditory canal varies between an adult and child. In a young client, the nurse pulls the ear down; in an adult client, the nurse pulls the ear up and back. The medication is not diluted; the number of medication drops instilled is as per the physician's prescription, and does not depend on the client's age. The position in which the client remains until the medication reaches the eardrum, and the amount of time before instilling medication in the client's opposite ear, does not differ with the age of the client.

To convert 0.8 grams to milligrams, the nurse should do which of the following?

Move the decimal point 3 places to the right. To convert a larger unit into a smaller unit, move the decimal point to the right (the new number is larger than the original). 1000 milligrams (mg) is equal to 1 gram (g); therefore 0.8 g is multiplied by 1000 (which is equivalent to moving the decimal point 3 places to the right) to determine how many mg it is equivalent to.

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?

Narrative Notes

A nurse charting the medical record for a client knows that which of the following forms of charting involves writing information about the client and client care in chronological order?

Narrative charting Narrative charting involves writing information about the client and client care in chronological order. In SOAP charting, everyone involved in the client's care makes entries in the same location in the chart. Focus charting follows a data, action, and response (DAR) model to reflect the steps in the nursing process. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order. A physician-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the physician and the nurse are legally responsible for these interventions.

Which of the following routes of medication administration is most commonly prescribed?

Oral Oral administration is the most commonly used route of administration. It is usually the route most convenient and comfortable for the patient.

A nurse is assigned to care for a client who is bleeding severely following an accident and has been ordered transfusion of blood components. What should the nurse do to reduce the risk of septic reactions?

Refrigerate red blood cells and thawed fresh frozen plasma until use. To minimize time for bacterial growth within the blood component and subsequent the risk for septic reactions, the nurse should refrigerate red blood cells and thawed fresh frozen plasma until use. Blood components should be infused within four hours of removal from the refrigerator. The nurse should not keep the frozen blood components at room temperature for an extended period of time because the longer they remain at room temperature, the more likely bacteria will grow and multiply. The nurse should use a blood warmer if necessary to warm blood and not immerse refrigerated blood components in warm water before use.

The nurse notes that the blood glucose level of a client has increased and is planning to notify the healthcare provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the healthcare provider?

SBAR The nurse should use SBAR to communicate verbally to the healthcare provider. Situation, Background, Assessment, and Recommendation (SBAR) is the communication tool to provide critical client information to the healthcare 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.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing?

SOAP charting The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

An acute care facility follows the unit dose supply method to supply medication to the clients. What is meant by the unit dose supply method?

Self-contained packets that hold one tablet or capsule for individual clients The nurse should understand that a unit dose supply method is a method in which self-contained packets hold one tablet or capsule for an individual client. An individual supply is a container with enough of the prescribed medication for several days or weeks and is common in long-term care facilities such as nursing homes. A stock supply remains on the nursing unit for use in an emergency or so that a nurse can give a medication without delay. Some facilities use automated medication-dispensing systems, which contain frequently used medications for that unit, any as-needed (PRN) medications, controlled medications, and emergency medications.

You are preparing to administer an intramuscular injection. After inserting the needle, you should gently pull back on the syringe plunger and observe for blood in the syringe.

TRUE

Which intervention does the nurse recognize as a collaborative intervention?

Teach the client how to walk with a three-point crutch gait. 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.

A nurse needs to administer a prescribed injection to a toddler. Which of the following injection sites is most suitable for the client?

Vastus Lateralis Site The vastus lateralis site is most desirable for administering injections to infants and small children, as well as clients who are thin or debilitated with poorly developed gluteal muscles. The dorsogluteal site is avoided in clients younger than 3 years because their gluteus maximus muscle is not sufficiently developed; whereas, the ventrogluteal site is safe for children. The deltoid site is the least-used intramuscular injection site because it is a smaller muscle than the others. It is used only for adults because the muscle is not sufficiently developed in infants and children.

A client taking insulin has his levels adjusted to ensure that the concentration of drug in the blood serum produces the desired effect without causing toxicity. What is the term for this desired effect?

Therapeutic Range A drug's therapeutic range is the concentration of drug in the blood serum that produces the desired effect without causing toxicity. The peak level, or highest plasma concentration, of the drug should be measured when absorption is complete. The peak level may be affected by factors that affect drug absorption as well as the route of administration. The trough level is the point when the drug is at its lowest concentration, and this specimen is usually drawn in the 30-minute interval before the next dose. A drug's half-life is the amount of time it takes for 50% of the blood concentration of a drug to be eliminated from the body.

On a home visit to a client, the client shows the nurse a medication that he purchased over-the-counter for relief of his arthritis pain. The client asks the nurse how it should be administered. The nurse reviews the medication and determines that it is to be applied to the skin. The nurse would instruct the client to most likely use which route of medication administration for this medication?

Transdermal The nurse should instruct the patient about the transdermal route for medication administration, which is used for topical agents, that is agents applied to the skin surface or mucous membranes. The intradermal route is a type of parenteral administration, while sublingual and buccal routes are for oral administration.

A client with chronic obstructive pulmonary disease has been prescribed an inhaled bronchodilator. Which of the following techniques should the nurse implement in order to ensure safe and complete delivery of the prescribed medication?

Use a spacer or extender with the metered-dose inhaler. The use of an extender or spacer ensures that the client receives as much of the inhaled medication as possible. MDIs are placed one to two inches in front of the mouth, not deeply into the mouth. Oxygen therapy prior to administration does not aid in delivery. Multiple puffs, if ordered, are given after 1 to 5 minutes.

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations?

When communicating a patient's change in condition to the patient's physician SBAR 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. SBAR is considered a framework for communication rather than a format for documentation.

A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality?

Writing the Client's name on the student care plan

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?

cognitive 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 is the primary purpose of the patient record?

communication The primary purpose of the patient record is to help healthcare professionals from different disciplines communicate with one another.

Which documentation tool will the nurse use to record the patient's vital signs every 4 hours?

graphic sheet A graphic sheet is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics. Acuity charting forms allow nurses to rank patients as high to low acuity in relation to the patient's condition and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the patient. The 24-hour fluid balance record form is used to document the intake and output of fluids for a patient with special needs.

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, patients:

have the right to copy their health records HIPAA affords patients the right to see and copy their health records, update their health records, and get a list of disclosures a healthcare institution has made for the purposes of treatment, payment, and healthcare operations. Patients have the right to request a restriction on certain uses or disclosures and choose how to receive this health information. HIPAA includes punishments for anyone caught violating patient privacy, but these punishments are not directed at the patient because HIPAA was implemented to protect the privacy of an individual's health information.

A client has come into the clinic for a postoperative visit. The client states that the postoperative pain continues to be 6 on a 10-point rating scale. The nurse evaluates the patient and the current plan of care. Based on the information provided by the client, the nurse should do which of the following?

modify the plan of care The nurse should evaluate the current status of the client and modify the plan of care to better meet the needs of the client at this time. There is no need to terminate the entire plan of care and continuation with the current plan will most likely keep the client dealing with pain. The nurse should ask the client if they are taking their pain medication as part of the assessment, not call the pharmacy.

According to the American Nurses Association, who determines the scope of nursing practice?

nurses

A nurse has a two-way video communication with the specialist involved in the care of a patient in a long-term care facility. This is an example of what nursing informatics technology?

telemedicine and mobile technology Telemedicine and mobile health technology facilitate client engagement, while helping providers deliver more cost-effective care. While telemedicine embraces applications and services that include two-way video communications, e-mail, and wireless phones, mobile health features multiple technologies integrated into the increasingly wireless and mobile health care delivery system. Patient engagement technology would include the concept of client portals, where clients could access an electronic medical record system and personal health information, online appointments scheduling, and personalized, condition-focused alerts and reminders in the form of e-mails, automated telephone calls, or text messages. Data aggregation is a process that involves data collection, analysis, use, reporting, and delivery of feedback throughout the organization. Organizations will use process and outcomes data to measure what they achieve for clients and population-based communities. Population health management technology perform data mining, risk stratification, and analysis. Searches can be conducted for disease trends, diagnoses, procedures, and missed appointments.

What is the primary purpose of the outcome identification and planning step of the nursing process?

to design a plan of care for and with the client Explanation: 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.

A client with an infection is receiving intravenous antibiotic therapy. The client has an intermittent infusion device in place. The nurse flushes the device with normal saline solution before administering the antibiotic based on which rationale?

to prevent blood clot formation The intermittent infusion devices are irrigated or flushed with a small quantity of sterile saline to prevent blood clot formation, thus maintaining patency. Irrigating the device with a small quantity of sterile saline does not facilitate cannulation of the central vein. The intermittent infusion device itself maintains venous access without requiring the client to receive continuous infusion, thus allowing increased mobility for the client and minimizing danger of fluid overload.

Which anatomic site is recommended for intramuscular injections for adults?

ventrogluteal muscles The ventrogluteal site involves the gluteus medius and gluteus minimus muscles in the hip area. This site is recommended for adults because there are no large nerves or blood vessels, it is removed from bone tissue, it is clean, and the patient may lie on the back, abdomen, or side for the injection.

A nursing student is performing an assessment on a client. Which of the following would the student record as subjective data? Select all that apply.

• "I am always anxious." • "My leg hurts when I move." • "I am so afraid of what my diagnosis is." Subjective data are information perceived only the the affected person.

A nurse is preparing to insert a peripheral intravenous (IV) device. The nurse determines that a winged infusion needle would be most appropriate. Which of the following might the nurse choose? Select all that apply.

• 19 gauge • 21 gauge • 23 gauge Explanation: Odd numbers designate winged infusion needles; therefore, the nurse could select a 19, 21, or 23 gauge needle. Even numbers designate IV catheters.

Which of the following are examples of breaches of client confidentiality? Select all that apply.

• A nurse updates the employer of a client regarding the client's return to work. • A nurse discusses a client with a coworker in the elevator. • A nurse shares her computer password with a relative of a client. Correct Explanation: 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.

Cognitively skilled nurses are critical thinkers. What are characteristics of a critical thinker? (Select all that apply.)

• Being open to all points of view • Resisting "easy answers" to patient problems • Thinking "outside the box" Being open to all points of view allows for the critical thinker to consider all possibilities when problem-solving. Resisting easy answers provides the critical thinker the opportunity to explore all potential answers when problem-solving, as well as prioritization of the answers. Thinking "outside the box" encourages that the best possible answer to the problem is chosen, rather than relying on the same generic answer that may not work for every situation. Basing thinking on the opinions of others does not foster exploration of new ideas or of critically thinking when problem-solving. Acting like a "know-it-all" prevents the acceptance of new ideas and collaboration. Accepting the status quo does not encourage discourages the principles of critical thinking.

Which of the following qualities does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply.

• Caring • Competence • Professionalism • Respect for client The nurse's interpersonal competence is critical beginning with the very first assessment. The client's initial impression is crucial. The nurse's competence, professionalism, and interpersonal qualities of caring and respect invite confidence and assure the client that help is available. How long the nurse has practiced does not influence this.

Which of the following qualities does the nursing student identify as being helpful in inviting the confidence of clients when first working with them? Select all that apply.

• Caring • Respect for client • Professionalism • Competence The nurse's interpersonal competence is critical beginning with the very first assessment. The client's initial impression is crucial. The nurse's competence, professionalism, and interpersonal qualities of caring and respect invite confidence and assure the client that help is available. How long the nurse has practiced does not influence this.

Which of the following are verbs that are helpful in writing measurable outcomes? Select all that apply.

• Define • Verbalize The verb should indicate the action that is to be performed. Examples include define, prepare, identify, design, list, verbalize, describe, choose, explain, select, apply, and demonstrate.

The nurse understands that when assessing a client, the primary source of client information is the client. However, the nurse identifies other sources of client information can include which of the following? Select all that apply.

• Family members accompanying the client • The client's health record • Other healthcare professionals • The client's support people When assessing,the primary source of client information is the client. Resources include the client's support people, the client record, information from other healthcare professionals and information from nursing and healthcare literature. It is not appropriate to use other clients as a source, since this violates confidentiality.

The nurse is performing an admission assessment on a young client admitted to the unit. Which of the following are considered objective data? Select all that apply.

• Height: 6' • 38 year-old man • Weight 195 pounds Objective data are observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing it.

A nurse is caring for a client who refuses to take the prescribed medication, stating that she is allergic to it. What should the nurse do when the client refuses to take the medication? Select all that apply.

• Identify the reason for not administering • Circle the scheduled time on the MAR • Report the situation to the prescriber When a client refuses the administration of a medication, the nurse needs to mention the reason why he or she did not administer the medication, circle the scheduled time on the MAR, and report the situation to the prescriber. The nurse should inform the prescriber, not the nurse manager, about the situation. The nurse also need not discuss the situation with the client; instead, the nurse should document the reason for not administering the medication.

The nursing instructor is demonstrating to the class how to perform a physical assessment. Which of the following assessment techniques should be demonstrated by the nursing instructor? Select all that apply.

• Inspection • Palpation • Percussion • Ausculation Four methods are used to collect data during the physical assessment: inspection, palpation, percussion, and auscultation. Documentation is done at the end but it is not a method used to collect data.

A nurse is preparing a seminar on the uses of documentation in client records. Which topics should the nurse include in the seminar? (Select all that apply.)

• Quality improvement • Research • Decision Analysis • Financial reimbursement Explanation: Quality improvement, research, decision analysis, and financial reimbursement are all uses for documentation. Market cost analysis and predictive outcome documentation are not uses for documentation.

Cognitively skilled nurses are critical thinkers. What are characteristics of a critical thinker? (Select all that apply.)

• Resisting "easy answers" to patient problems • Being open to all points of view • Thinking "outside the box

A nurse needs to administer a subcutaneous injection to a client. Which of the following techniques should the nurse use to reduce discomfort? Select all that apply.

• Support the client's tissue when withdrawing the needle • Numb the skin with an ice pack before the injection • Insert and withdraw the needle without hesitation • Instill the medication slowly but steadily The nurse can reduce discomfort associated with injections by using alternative techniques such as numbing the skin with an ice pack before the injection, inserting and withdrawing the needle without hesitation, and instilling the medication slowly and steadily. Nurses use the Z-track method for intramuscular injections, not for any other injection. Supporting the tissue during withdrawal reduces discomfort.

A nursing student is developing an outcome criterion for an assigned client. The student demonstrates understanding by including information that answers which questions? Select all that apply.

• Who • What actions • Under what circumstances • How well • When Explanation: To be specific and measurable, outcome criteria should meet certain requirements. Outcome criteria answer the questions who, what actions, under what circumstances, how well, and when. Answering the question of "why" is not involved.