Nursing Process

Which component of an outcome criterion must the nurse consider when setting goals for a client?

A time frame

What guides professional practice?

ANA Standards of Nursing Practice

The nurse who is caring for a child admitted after an automobile accident recognizes the importance of including the child's family in the plan of care. Inclusion of the family meets which of Maslow's basic human needs?

Love and belonging

After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first?

a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular

The nurse receives report on the assigned clients at the beginning of the second shift. Which client should the nurse plan to assess first after receiving report?

an elderly client with pneumonia who is exhibiting periods of confusion

During the planning step of the nursing process, the nurse:

establishes short- and long-term goals.

The nurse on the orthopedic unit is receiving a client from the Post Anesthesia Care Unit (PACU). WA safe "hand-off" includes:

interactive communication between the nurse from the PACU and the nurse from the orthopedic unit.

A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?

"The client remains free of signs and symptoms of phlebitis."

A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make?

"Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions."

A D P I E

Assessment Diagnosis Plan Implement Evaluate

A nurse, when documenting the health details of a client in an acute care agency, fills out all the details under assessment, diagnosis, planning, and implementation. What did the nurse miss as per the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) standards?

Evaluation of outcomes.

An elderly client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client?

Hyperthermia

A client is breathing 40 breaths/minute. He is diaphoretic and confused. Which nursing diagnosis should be the priority for the client at this time?

Impaired gas exchange

When performing an assessment, the nurse identifies the following signs and symptoms: discoordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis?

Impaired physical mobility

A client who received general anesthesia returns from surgery. Post operatively, which nursing diagnosis takes highest priority for this client?

Ineffective airway clearance related to anaesthesia

The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month five clients were diagnosed with pressure ulcers. The nurse manager should:

Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes.

A client with Alzheimer's disease is brought to the emergency department. A focused plan of care by the nurse would include which of the following?

Provide consistent and familiar care to the client.

While caring for a client who's immobile, a nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?

Risk for impaired skin integrity related to immobility

The following statement appears on a client's care plan: "Client will ambulate in the hall without assistance within 4 days." This statement is an example of:

a client outcome.

A client is placed on a low-sodium (1500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective?

"I chose broiled chicken with a baked potato for dinner."

The nurse is reflecting on the evaluation step of the nursing process. Which documentation would indicate nursing actions were effective in reducing breathing problems for a client?

Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min Lung sounds clear bilaterally with non-labored respirations noted

The nurse is preparing a teaching plan for a 45-year-old client recently diagnosed with type 2 diabetes mellitus. What is the first step in this process?

Assess the client's learning needs.

A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is she performing?

Assessment

A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, which nursing diagnosis should be the nurse's priority?

Deficient knowledge related to food restrictions associated with anesthesia

Following the creation of an ileostomy, a client states, "I am really worried about how I am going to manage this thing." The first action of the nurse should be to:

Determine the client's exact concerns about the ileostomy.

A nurse refers a client with terminal cancer to a local hospice. What is the goal of this referral?

To help the client and his family manage the terminal illness

A nurse is planning care for an elderly client with cognitive impairment who is still living at home. Which action should the nurse identify as a priority for safety in planning care for this client?

ensuring the removal of objects in the client's path that may cause him to trip

A nurse is conducting an intake assessment and wants to determine a client's ethnicity. Which of the following is the best way for the nurse to conduct this assessment?

Ask whether the client identifies with a particular culture or ethnic group.

A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client?

Deficient fluid volume related to nausea and vomiting

A client who is being treated for non-healing diabetic foot ulcers tells the nurse angrily, "I am so frustrated with my doctors. The wound care doctor tells me this will not heal and I need to have my toes amputated and another doctor tells me I need to keep going with the antibiotics and dressing changes so I can save my foot. I just want to go home!" After listening to the client's concerns, the nurse should:

contact the client's case manager to set up a care conference.

When obtaining a client's history, the nurse should:

ask questions about the client's reason for seeking care.