Nurs 211 Chapter 16: Outcome Identification and Planning

Which action should the nurse perform during the planning phase of the nursing process? -Assess the client's overall health. -Identify measurable goals or outcomes. -Analyze the client's response to medicines. -Identify the client's health-related problems.

Identify measurable goals or outcomes.

These nursing diagnoses appear on a client's care plan. In what order will the nurse prioritize them? 1. Impaired Swallowing 2. Fluid Volume Deficit 3. Risk for Impaired Skin Integrity 4. Altered Body Image

Impaired Swallowing Fluid Volume Deficit Risk for Impaired Skin Integrity Altered Body Image

A computerized information system developed to classify client outcomes is the: -NANDA-International list -Nursing Outcome Classification system -International Classification of Diseases -Clinical Care Classification System

Nursing Outcome Classification system

Which is most important for the nurse to include in a client's plan of care? -Nursing interventions -Evaluation -Assessment data -Medical diagnoses

Nursing interventions

Which phase of the nursing process most involves establishing priorities? -Assessment -Diagnosis -Outcome identification and planning -Implementation

Outcome identification and planning

What are specific measurable and realistic statements of goal attainment? -Nursing diagnoses -Nursing interventions -Evaluations -Outcomes

Outcomes

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem? -Client will not leave the premises without a caregiver. -Client will wear an ID bracelet with name and contact information. -Client will identify landmarks that indicate location of home. -Client will consistently return to the police station when lost.

Client will not leave the premises without a caregiver.

A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement? -Adjust expected outcome to have client ambulate a shorter distance. -Return the client to bed and provide pain relief measures. -Ask the client to describe a personal walking goal. -Review evidence-based interventions for the client's pain.

Return the client to bed and provide pain relief measures.

Which action should the nurse perform during the planning step of the nursing process? -Interprets and analyzes the client data -Establishes a database for the client -Identifies client strengths and weaknesses -Selects nursing measures, including client education

Selects nursing measures, including client education

A client has just given birth to a stillborn infant. The client is sobbing and says God is punishing the client for some bad choices in the past. The client reports having always believed in God as a loving and caring presence in life but now feeling that the client's faith is destroyed. Which nursing diagnoses would be appropriate for the nurse to include in this client's care plan? Select all that apply. -Spiritual Distress -Risk for Suicide -Defensive Coping -Impaired Parenting -Grieving

Spiritual Distress Grieving

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 not made any error in writing the outcome. -The nurse has omitted the time frame. -The nurse has omitted the defining characteristics. -The outcome should indicate what the nurse will do.

The nurse has omitted the time frame.

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "The client will know how to self-administer prescribed bronchodilators using a nebulizer by 09/09/2020." Why is this outcome inadequate? -The outcome is not observable or measurable. -The outcome is not related to an independent nursing action. -The outcome does not specify the conditions in which it will be achieved. -The statement expresses a client outcome as a nursing intervention.

The outcome is not observable or measurable.

The nurse is developing goals for a newly admitted client with visual and auditory hallucinations. Which outcome is the priority for the client? -Client will understand that the hallucinations aren't real in therapy sessions before discharge. -Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior. -Client will verbalize side effects of antipsychotic medications within 24 hours. -Within 2 days, client will perform personal hygiene without reminders.

Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior.

The nurse has established client outcomes and outcome criteria. What should the nurse do next? -Establish priorities -Write a client plan of care -Determine client goals -Identify objectives

Write a client plan of care

The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is: -a clinical pathway. -an order set. -an algorithm. -a protocol.

a clinical pathway

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: -a guideline. -an algorithm. -a critical pathway. -an order set.

a guideline

The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually -does not contain documented scientific rationales. -does not contain abbreviated nursing diagnoses. -separates goal statements from the plan of care. -separates outcome criteria from the plan of care.

does not contain documented scientific rationales.

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? -Surveillance -Maintenance -Supervisory -Educational

educational

A client is unconscious and unable to provide input into outcome identification. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes? -Family -Physical therapists -Occupational therapists -Pharmacists

family

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning? -Ongoing -Initial -Discharge -Outcome

ongoing

The primary purpose of developing expected client outcomes is to: -document nursing practice. -evaluate nursing interventions. -focus on health promotion. -provide individualized care.

provide individualized care.

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? -Maintenance -Surveillance -Psychomotor -Psychosocial

psychomotor

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? -"Client will learn to cope more effectively." -"Client will list positive coping strategies and use them." -"Client will identify one coping strategy to try by end of week." -"Client tries using relaxation as a means to cope."

"Client will identify one coping strategy to try by end of week."

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? -"You need to stop smoking for us to effectively combat this disease." -"Please tell me your thoughts about treating this diagnosis." -"Do you want to be discharged without treatment?" -"What are your plans after discharge?"

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

The nurse has identified short- and long-term goals for a client after surgery to remove a leg tumor. When determining interventions for the goals, which questions are important for the nurse to consider? Select all that apply. -Are the interventions compatible with other planned therapies? -Are the interventions evidence-based? -Are the interventions realistic and do they require resources available to the nurse? -Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background? -Are the interventions valued by the nursing staff?

-Are the interventions compatible with other planned therapies? -Are the interventions evidence-based? -Are the interventions realistic and do they require resources available to the nurse? -Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background?

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins? -Interrupted Breastfeeding -Ineffective Thermoregulation -Altered Gas Exchange -Impaired Parenting

Altered Gas Exchange

Which client outcome requires modification? -Client will correctly self-administer subcutaneous insulin before discharge. -By the end of instruction, client will know how to perform dressing changes. -Client will demonstrate safe transfers from bed to chair within 24 hours. -Within 2 days, client will describe two responses to firing of the internal defibrillator.

By the end of instruction, client will know how to perform dressing changes.

Which outcome is sufficiently measurable? -Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020. -Client will progress from clear fluid diet to full fluid diet without experiencing nausea. -Increase client's diet from clear fluids to full fluids by 12/15/2020. -Client will maintain adequate intake with no reports of nausea by 12/15/2020.

Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020.

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs? -Cutting up food and opening drink containers for the client -Seeking input from the client regarding preferences for a snack -Providing the mother the phone number for the Poison Control Center -Assisting the client to validate feelings regarding treatment options

Cutting up food and opening drink containers for the client

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client 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? -Choosing actions that do not solve the problem -Failing to update the written plan of care -Beginning the plan without family to help -Developing the plan without client input

Developing the plan without client input

A nurse administers colchicine according to the standardized plan of care for a client admitted with acute gouty arthritis of the right great toe. Which assessment information deviates from the expected client outcome for the first 12 hours and requires nursing intervention? -Uric acid level decreases. -Client walks to the bathroom. -Foot remains red and swollen. -Client reports diarrhea.

Foot remains red and swollen.

Which outcome for a client with a new colostomy is written correctly? -Explain to the client the proper care of the stoma by 3/29/20. -The client will know how to care for the stoma by 3/29/20. -The client will demonstrate proper care of the stoma by 3/29/20. -The client will be able to care for stoma and cope with psychological loss by 3/29/20.

The client will demonstrate proper care of the stoma by 3/29/20.

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 not made any error in writing the outcome. -The nurse has omitted the time frame. -The nurse has omitted the defining characteristics. -The outcome should indicate what the nurse will do.

The nurse has omitted the time frame.

When creating a care plan, which is the purpose of identifying the client outcome? -To design a plan of care to address the health problem -To evaluate the plan of care developed -To provide a basis for the scientific rationale -To coordinate the nursing intervention

To design a plan of care to address the health problem

Which is an example of a psychomotor outcome? -Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. -Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. -The client will verbalize understanding of the need to continue to take medications as prescribed. -The client's skin will remain smooth, moist, and without breakdown or ulceration.

Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: -identifies the unhealthy response preventing desired change. -identifies factors causing undesirable response and preventing -desired change. -suggests client goals to promote desired change. -identifies client strengths.

identifies factors causing undesirable response and preventing desired change.

The nurse recognizes that identifying outcomes/goals must include: -involvement of the client and family. -input from the physician. -input from the multidisciplinary team. -involvement of the nurse manager and other staff nurses.

involvement of the client and family.

According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is: -physiological. -behavioral. -safety. -family.

physiological

A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client? -Insomnia -Fatigue -Agitated Movement -Ineffective Impulse Control

Ineffective Impulse Control

A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client? -The client will perform range of motion exercises 3 times per day. Passive abduction with assistance -The client was able to abduct from 0 to 90 degrees with assistance. -The client will continue to perform range of motion 3 times per day. -The client performed active range of motion exercises only twice today but states a goal of 3 times per day tomorrow.

Passive abduction with assistance

A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest, and the nurse provides assistance with position change every 2 hours to prevent pressure injuries. What is the "to prevent pressure injuries" portion of this statement described as? -Rationale -Outcome -Nursing intervention -Nursing diagnosis

Rationale

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care? -Consult with another nurse. -Seek research about the disorder. -Follow institutional guidelines. -Set priorities using client care standards.

Seek research about the disorder.

Which guideline should the nurse follow when including interventions in a plan of care? -Make sure the nursing interventions are unrelated to the original outcomes. -Date the nursing interventions when written and when the plan of care is reviewed. -Make sure the attending physician approves of and signs the nursing interventions. -Make sure each nursing intervention does not describe the action the nurse should perform.

Date the nursing interventions when written and when the plan of care is reviewed.

Which are characteristics of appropriate client outcome statements? Select all that apply. Measurable Realistic Specific Short-term Broad in scope

Measurable Realistic Specific

Which statement correctly describes a nurse-initiated intervention? -Nurse-initiated interventions are derived from the nursing diagnosis. -Nurse-initiated interventions require a physician's order. -Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. -Nurse-initiated interventions are actions performed to diagnose a medical problem.

Nurse-initiated interventions are derived from the nursing diagnosis.

Which is an example of a psychomotor outcome? -Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. -Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. -The client will verbalize understanding of the need to continue to take medications as prescribed. -The client's skin will remain smooth, moist, and without breakdown or ulceration.

Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.

A client had a cholecystectomy 2 hours previously and is waking up from anesthesia. The client asks, "how long it will be before I can go home?" The nurse responds that most clients are discharged within 2 days. The nurse's answer is most likely based on which piece of information? -The individualized plan of care -The scientific rationale -The agency's critical path -The client outcomes

The agency's critical path

The nurse should derive the outcomes for a client's care plan from: -the problem statement of the nursing diagnosis. -the defining characteristics in the nursing diagnosis statement. -assessment data gleaned from the physician's progress notes. -assessment data provided by the multidisciplinary team.

the problem statement of the nursing diagnosis.

A nurse is developing the postoperative plan of care for a client admitted with a fractured hip who has undergone surgery to repair it. Which intervention would the nurse identify as a nurse-initiated intervention? Select all that apply. -Assess the client's pain level every 2 hours. -Administer prescribed opioid analgesic every 4 hours as needed. -Turn the client every 2 hours per turning schedule. -Teach the client how to perform relaxation as a pain relief strategy. -Obtain complete blood count and chest x-ray in the morning.

-Assess the client's pain level every 2 hours. -Turn the client every 2 hours per turning schedule. -Teach the client how to perform relaxation as a pain relief strategy.

For which client would a standardized plan of care most likely be appropriate? -A client who was admitted for shortness of breath and who has been diagnosed with pneumonia -A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy -A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem -A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority? -Client will discuss drinking habits in therapy sessions the day after admission. -By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms -Client will commit to completing a 12-step program within 24 hours of admission. -Within 3 days, client will be discharged.

By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms

Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer? -By the next clinic visit, the client will report needing antiemetic medication. -After attending a cancer support group, the client will report being in a good mood. -By discharge, the client will perform hand hygiene before and after port care. -The client will schedule radiation therapy sessions and plan for chemotherapy.

By discharge, the client will perform hand hygiene before and after port care.

Which client outcome requires modification? -Client will correctly self-administer subcutaneous insulin before discharge. -By the end of instruction, client will know how to perform dressing changes. -Client will demonstrate safe transfers from bed to chair within 24 hours. -Within 2 days, client will describe two responses to firing of the internal defibrillator.

By the end of instruction, client will know how to perform dressing changes.

A nurse plans a series of muscle-strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. The client is unsuccessful when the new strategies are implemented. Which action by the nurse may have led to failure to meet the outcome? -Choosing actions that do not solve the problem -Failing to update the written plan of care -Beginning the plan without family to help -Stating outcomes too broadly

Choosing actions that do not solve the 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 reports no headache. -Client is drowsy after lunch. -Client is normotensive. -Client lipids are within range.

Client is normotensive.

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem? -Client will alternate rest periods with exercise throughout the day. -Client will increase protein intake in small frequent meals. -Client will use oxygen by nasal cannula when short of breath. -Client will consistently perform pulmonary exercises.

Client will alternate rest periods with exercise throughout the day.

Which is an appropriate expected outcome for a client? -By the next clinic visit, client will report taking antihypertensive medication. -After attending sibling classes, client will be happy about a new baby and demonstrate feeding. -Client will ambulate safely with walker in the room within 3 days of physical therapy. -Client will perform complete ostomy care while bathing on the second postoperative day.

Client will ambulate safely with walker in the room within 3 days of physical therapy.

The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. What short-term client goals help prepare the client for discharge? Select all that apply. -Client will receive influenza vaccine. -Client will increase nutrition, eating 75% of meals. -Client will report pain is controlled at or below 3 of 10. -Client will maintain oxygen saturation at 81%. -Client will perform dressing change independently.

Client will increase nutrition, eating 75% of meals. Client will report pain is controlled at or below 3 of 10. Client will perform dressing change independently.

A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective? -Client will use chin tuck and double swallow for each bite. -Client will avoid straws and drink thickened liquids. -Client will sit in chair for all meals and snacks. -Client will chew food well and use a tongue sweep.

Client will use chin tuck and double swallow for each bite.

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse? -Encourage hourly use of the incentive spirometer. -Promote oral fluid intake between meals. -Provide oral pain medication before ambulation. -Reassess in 4 hours and document the findings.

Encourage hourly use of the incentive spirometer.

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? -Individualize the plan to the client. -Expect to modify the plan significantly. -Identify the appropriate nursing diagnoses. -Include the rationale for the interventions.

Individualize the plan to the client.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: -diagnosis. -evaluation. -intervention. -goal.

Intervention

Which elements are important to incorporate into a client's plan of care? Select all that apply. -Client participation -Care that is realistic and measurable -Involvement of support people -Standardized care

Involvement of support people Care that is realistic and measurable Client participation

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? -Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. -The nurse will help the client ambulate the length of the hallway once a day. -Offer to help the client walk the length of the hallway each day. -The client will become mobile within a 24-hour period.

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

Which statement on a plan of care should a nurse identify as a nursing intervention? -The client self-administered insulin correctly following education. -The client will correctly demonstrate deep-breathing exercises after education. -Perform range-of-motion exercises to all of the client's joints each morning. -Readiness for Enhanced Communication

Perform range-of-motion exercises to all of the client's joints each morning.

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs? -Start from client's knowledge, teach about diet modifications, and check for learning. -Present the client with videos and books about diet changes that reduce inflammation. -Ask the client's learning style, then teach diet information using that style. -Answer the client's questions about diet alterations, and then evaluate understanding.

Start from client's knowledge, teach about diet modifications, and check for learning.

Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal? -Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. -Assist the client to put on the clothing that goes over the operated leg. -Tell the client's family to bring in clothes a size larger to make dressing easier. -Arrange for the social worker to schedule home health care with discharge planning.

Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender.

Which is an example of a nurse-initiated intervention? -Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. -Administer oxygen at 4 L/min per nasal cannula. -Administer a 1000-mL soap suds enema. -Teach the client how to splint an abdominal incision when -coughing and deep breathing.

Teach the client how to splint an abdominal incision when coughing and deep breathing.

The nurse recognizes that an example of a cognitive outcome is: -The client demonstrates self-catheterization using clean technique by June 3. -The client identifies three foods high in potassium by August 8. -The client accurately measures the radial pulse for 1 minute by February 2. -The client verbalizes increased confidence in testing glucose levels.

The client identifies three foods high in potassium by August 8.

A client is on the surgical unit following resection of an intestinal tumor. The client is alert and oriented x3. Based on an assessment of the client, the physician writes a medical order to "ambulate with assistance" in the chart. This will be the client's first time ambulating. Which is the best nursing outcome for this client? -The client will ambulate with the assistance of a walker without falling within the next 4 hours. -Physical therapy will be consulted to assist the client with ambulation. -The client will ambulate to the restroom 3 times this shift. -The client will ambulate with the assistance of a walker sometime today.

The client will ambulate with the assistance of a walker without falling within the next 4 hours.

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision? -The client will understand the effects of smoking related to heart disease. -By 08/02, the client will state three therapeutic methods of reducing stress. -By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. -By 8/02, the client will state when to notify the health care provider after discharge

The client will understand the effects of smoking related to heart disease.

A client in the intensive care unit with a nursing diagnosis of Risk for Impaired Skin Integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to the client's left side, the nurse notices that the client has a nonblanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take? -The nurse repositions the client to the client's back and documents the intervention in the client's record. -The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour. -The nurse repositions the client to the left side and plans to return in 2 hours to reassess the reddened area on the client's right trochanter. -The nurse repositions the client to the client's back and documents the condition of the client's skin in the medical record.

The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour.

A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client? -Posting the sign "NPO after midnight" over the bed -Updating the diet orders in the client's plan of care -Obtaining written consent for the diagnostic procedure -Adding the diagnosis "Altered Nutrition, Less Than Required"

Updating the diet orders in the client's plan of care

Nurses on an orthopedic nursing unit use standardized care plans that incorporate nursing, physical therapy, occupational therapy, and case management actions for clients who experience a particular surgery. Which type of care plan do these nurses use? -Clinical pathway -Computer database -Nursing diagnosis -Concept map

clinical pathway

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan? -Initial -Ongoing -Discharge -Standardized

standardized

The nurse is determining realistic nursing interventions for a client on bed rest after a colon resection. What interventions would best meet the needs of this client? Select all that apply. -Assist the client with deep breathing exercises with the use of incentive spirometry every hour. -Turn the client and change position every 2 hours. -Assist the client with ambulation when the client feels better. -Administer acetaminophen every 6 hours for treatment of pain. -Provide the client with a pillow to splint the abdomen and assist with coughing every 2 hours.

-Assist the client with deep breathing exercises with the use of incentive spirometry every hour. -Turn the client and change position every 2 hours. -Provide the client with a pillow to splint the abdomen and assist with coughing every 2 hours.

A nurse is caring for a client admitted for bowel obstruction, which now has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply. -Allow the client to order favorite foods from the hospital menu. -Auscultate for bowel sounds. -Begin feedings with clear broth. -Consult with a dietitian regarding appropriate foods.

-Auscultate for bowel sounds. -Begin feedings with clear broth. -Consult with a dietitian regarding appropriate foods.

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care? -Add the nursing diagnosis: Risk for Self-Harm. -Tell another nurse about this client statement. -Encourage the client to join a therapy group. -Document that the depression has resolved.

Add the nursing diagnosis: Risk for Self-Harm.

A nurse writes down the following outcome for a depressed client: "By 6/9/20, the client will state three positive benefits of receiving counseling." This is an example of which type of outcome? -Psychomotor -Cognitive -Affective -Realistic

Affective

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client's and family's ability to cope. What action should the nurse take with this client? -Comfort the client and family. -Provide more information about diabetes. -Test the client's blood glucose levels. -Ask the client whether anyone else in the client's family also has diabetes.

Comfort the client and family.

Which provides the best framework for prioritizing client problems? -Availability of hospital resources -Family member statements -Maslow's hierarchy of needs -Nursing skill

Maslow's hierarchy of needs

Which are characteristics of appropriate client outcome statements? Select all that apply. -Measurable -Realistic -Specific -Short-term -Broad in scope

Measurable Realistic Specific

A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client? -The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. -The client will express an understanding of strategies for managing fatigue and shortness of breath. -The client will ambulate 100 feet without supplementary oxygen or mobility aids. -The client will demonstrate the correct use of a metered-dose inhaler.

The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath.

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining? -Process -Structure -Outcome -Cost-effectiveness

outcome

The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate? -"Nursing interventions are selected based on the etiology in the nursing diagnosis and must be compatible with other therapies planned for the client." -"The client's developmental level, values, beliefs, and cultural and psychosocial background should be considered when selecting nursing interventions." -"Nursing interventions should be consistent with standards of nursing care and research findings." -"Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

"Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

Which are correctly written nursing interventions? Select all that apply. -Provide 5 to 6 small meals daily. -Reposition the client from side to side every hour around the clock. -Provide opportunities for the client to express concerns and verbalize feelings. -Understand the side effects of furosemide. -Know the signs and symptoms of infection.

-Provide 5 to 6 small meals daily. -Reposition the client from side to side every hour around the clock. -Provide opportunities for the client to express concerns and verbalize feelings.

What behaviors reflect planning? Select all that apply. -The nurse decides to assist the client with ambulation in the hallway twice per shift. -The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. -The nurse considers the developmental level of the client when selecting education materials. -The nurse assesses the client's usual sleep routine. -The nurse assists the client with bathing, grooming, and dressing.

-The nurse decides to assist the client with ambulation in the hallway twice per shift. -The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. -The nurse considers the developmental level of the client when selecting education materials.

The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highestpriority for care? -A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious -A 68-year-old woman with bruises across the chest and lower abdomen who is observed rubbing the bruised area on the lower abdomen and moaning -A 4-year-old with a deformed left lower leg with equal pedal pulses in both feet and who is crying loudly -An 18-year-old woman sitting up in bed with an egg-size hematoma and a 5-cm laceration on the forehead who is talking rapidly on a cell phone

A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious

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. -Ask the client what the priority needs are. -Consult the oncology nurse specialist in order to determine priorities. -Hold a unit meeting to determine needs.

Include the client and the client's power of attorney in the discussion.

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? -Narcotic analgesic to treat pain -Septic workup due to blood pressure and heart rate elevation -Isolation for suspected respiratory illness -Acetaminophen to treat pain and fever

Narcotic analgesic to treat pain

Which are correctly written nursing interventions? Select all that apply. -Provide 5 to 6 small meals daily. -Reposition the client from side to side every hour around the clock. -Provide opportunities for the client to express concerns and verbalize feelings. -Understand the side effects of furosemide. -Know the signs and symptoms of infection.

Provide 5 to 6 small meals daily. Reposition the client from side to side every hour around the clock. Provide opportunities for the client to express concerns and verbalize feelings.

The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is: -a clinical pathway. -an order set. -an algorithm. -a protocol.

a clinical pathway.

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: -a guideline. -an algorithm. -a critical pathway. -an order set.

a guideline.

A nurse is reviewing the plan of care for a client and notes: "The client will verbalize three signs of hypoglycemia to the staff accurately before discharge." The nurse should identify this statement as an example which element of nursing practice? -Nursing diagnosis -Outcome -Intervention -Evaluation

outcome

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? -Supportive -Psychosocial -Coordinating -Supervisory

supportive

The nurse should derive the outcomes for a client's care plan from: -the problem statement of the nursing diagnosis. -the defining characteristics in the nursing diagnosis statement. -assessment data gleaned from the physician's progress notes. -assessment data provided by the multidisciplinary team.

the problem statement of the nursing diagnosis.