Prep U's - Chapter 16 - Outcome Identification and Planning (TF)

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? A. Client is normotensive. B. Client reports no headache. C. Client is drowsy after lunch. D. Client lipids are within range.

Answer: A Rationale: 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 and 120/80 mm Hg. The other options do not directly indicate successful control of hypertension.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? A. Client will maintain adequate hydration within 2 days. B. Client will have formed stools within 24 hours. C. Client will identify the food that caused the condition within 3 hours. D. Client will eat small meals of bland foods for 3 days.

Answer: B Rationale: Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal.

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

Answer: C Rationale: A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance client goals and outcomes. Nursing diagnoses are statements of the client's actual or potential health problems that the nurse is seeking to address through interventions and are the overarching driver of goal-setting, care planning, and interventions. Evaluation, the final phase of the nursing process, involves assessing the client's response to interventions on an ongoing basis and making any necessary adjustments and changes to the nursing care plan.

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. A standardized care plan. B. An algorithm. C. An order set. D. Guidelines.

Answer: A Rationale: 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. An algorithm in nursing is a set of developed evidence-based clinical practice guidelines that guides nursing interventions. A guideline is a statement by which to determine a course of action. An order set is a predetermined set of orders by a prescriber that dictates care of the client.

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? A. Seek research about the disorder. B. Consult with another nurse. C. Follow institutional guidelines. D. Set priorities using client care standards.

Answer: A Rationale: While each option is appropriate, it is crucial to find research to support the plan before establishing priorities. The nurse planning care uses clinical reasoning to set priorities that incorporate standards and agency policies, identify and record expected client outcomes, select evidence-based nursing interventions, and record the plan of care.

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. A. Auscultate for bowel sounds. B. Begin feedings with clear broth. C. Allow the client to order favorite foods from the hospital menu. D. Consult with a dietitian regarding appropriate foods.

Answer: A, B, D Rationale: Feedings should begin slowly with clear liquids as the first food. Immediately resuming a standard diet after a period of having nothing by mouth is likely to result in gastrointestinal distress. It is appropriate for the nurse to monitor bowel sounds and to consult with the dietician.

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

Answer: B Rationale: A nursing intervention is a treatment that the nurse performs to enhance client outcomes, such as "Perform range-of-motion exercises to all of the client's joints each morning." "The client self-administered insulin correctly following education" is an evaluative statement that the nurse might document to indicate the effectiveness of client education related to insulin self-administration. "The client will correctly demonstrate deep-breathing exercises after education" is an expected client outcome. "Readiness for Enhanced Communication" is a health promotion nursing diagnosis.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? A. Client will eat small meals of bland foods for 3 days. B. Client will have formed stools within 24 hours. C. Client will maintain adequate hydration within 2 days. D. Client will identify the food that caused the condition within 3 hours.

Answer: B Rationale: Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal.

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? A. By 8/02, the client will state when to notify the health care provider after discharge. B. By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. C. By 08/02, the client will state three therapeutic methods of reducing stress. D. The client will understand the effects of smoking related to heart disease.

Answer: D Rationale: Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." These verbs are too general and cannot be measured. Verbs for writing outcomes should be observable and measurable. The verbs in the distractors are all measurable. The correct response has a goal that the nurse will be unable to measure.

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? A. Maintenance B. Surveillance C. Psychomotor D. Psychosocial

Answer: C Rationale: Psychomotor interventions include activities such as positioning, inserting, and applying. A psychosocial intervention focuses on supporting, exploring, and encouraging. Maintenance and surveillance are monitoring interventions.

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

Answer: D Rationale: A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nurse-initiated interventions, such as teaching, do not require a health care provider's order. A health care provider's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? A. Once the client is admitted to the nursing unit from postanesthetic recovery. B. As soon as possible after the client's surgery. C. Once the client has received a discharge order. D. On the client's admission to the hospital.

Answer: D Rationale: Discharge planning should begin when a client is admitted for treatment. All the other times listed are too late and are not consistent with a client who is able to understand the process of the hospitalization.

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

Answer: A, D, E Rationale: Expected client outcomes should be specific (not broad in scope), measurable, realistic statements of goal attainment. They may restate the goal, but they also present information that will guide the evaluation phase of the nursing process. To be specific and measurable, certain requirements must be met when writing outcomes. Outcomes answer the questions who, what actions, under what circumstances, how well, and when. Outcomes may be short- or long-term and include a range of expectations about what the client's condition will be after nursing intervention.

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? A. Supportive B. Coordinating C. Supervisory D. Psychosocial

Answer: A Rationale: Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems. Coordinating interventions involve many different activities, such acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall health care.

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? A. Reassess in 4 hours and document the findings. B. Encourage hourly use of the incentive spirometer. C. Promote oral fluid intake between meals. D. Provide oral pain medication before ambulation.

Answer: B Rationale: Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve this problem. Reassessment is needed, but this does not replace the need for interventions.

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? A. Discharge B. Initial C. Ongoing D. Standardized

Answer: D Rationale: Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. Initial, ongoing, and discharge are not types of care plans but of planning, in general. Typically, the nurse develops the client's care plan during initial planning and then updates it as needed during ongoing and discharge planning.

What are specific measurable and realistic statements of goal attainment? A. Nursing interventions B. Evaluations C. Outcomes D. Nursing diagnoses

Answer: C Rationale: Expected client outcomes are specific, measurable, realistic statements of a client's goal attainment. Nursing diagnoses, interventions, and evaluation do not apply to outcomes or goals of nursing care. Nursing diagnoses are statements describing a client's actual or potential health problems that the nurse can treat independently using nursing interventions. Nursing interventions are the actions nurses take to treat the client's health problems. Evaluations are assessments of the effectiveness of interventions in resolving clients' health problems.

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

Answer: A Rationale: Expected client outcomes must be client-centered, specific, measurable, attainable, realistic, and time-bound. "The client will demonstrate proper care of the stoma by 3/29/20" has all of these characteristics. "Explain to the client the proper care of the stoma by 3/29/20" is a nursing intervention, not an outcome. "The client will know how to care for the stoma by 3/29/20" is not measurable. The client demonstrating a technique is measurable. "The client will be able to care for stoma and cope with psychological loss by 3/29/20" contains two goals in one statement.

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

Answer: A Rationale: In the planning phase of the nursing process, the nurse identifies measurable goals or outcomes, prioritizes nursing diagnoses and collaborative problems, selects appropriate interventions, and documents the plan of care. The nurse assesses the client's overall health during the assessment step of the nursing process, not during the planning step. The nurse identifies the client's health-related problems during diagnosis and analyzes the client's response to medicines during the evaluation process.

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

Answer: A Rationale: Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis and do not require a health care provider's order. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client. They are not performed to diagnose any problem, medical or otherwise, but to help prevent or resolve a problem identified in a nursing diagnosis and thereby to achieve the related expected client outcome.

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

Answer: A Rationale: Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis and do not require a health care provider's order. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client. They are not performed to diagnose any problem, medical or otherwise, but to help prevent or resolve a problem identified in a nursing diagnosis and thereby to achieve the related expected client outcome.

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

Answer: A Rationale: Outcomes may be categorized according to the type of change they describe for the client. Psychomotor outcomes describe the client's achievement of new physical skills, such as changing an abdominal dressing. Cognitive outcomes describe an increase in the client's knowledge, such as understanding the need to continue to take medications as prescribed. Affective outcomes describe changes in client values, beliefs, and standards, such as decreasing the number of cigarettes one smokes due to adopting a belief that smoking is harmful. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved, such as a client's skin not developing breakdown or ulceration.

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? A. The agency's critical path. B. The client outcomes. C. The individualized plan of care. D. The scientific rationale.

Answer: A Rationale: The critical path is based on large bodies of research and provides information on a client's expected course for a specific treatment or illness. Deviations from the critical path are documented in the individualized plan of care. Because the nurse refers to a standard process, it is clear that it is not based on the client's individualized plan of care, which applies only to that client. Although the critical path itself is based on scientific rationale, the nurse in this case is not citing that rationale directly but rather the critical path. The client expected outcomes would be the goals that the nurse has set for this particular client, which would not pertain to the experience of "most clients."

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? A. Start from client's knowledge, teach about diet modifications, and check for learning. B. Ask the client's learning style, then teach diet information using that style. C. Answer the client's questions about diet alterations, and then evaluate understanding. D. Present the client with videos and books about diet changes that reduce inflammation.

Answer: A Rationale: The nursing interventions written to assist a client to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what assessments need to be made and what nursing interventions, including teaching, counseling, and advocacy, need to be done. They should also include evaluation of the outcome of the intervention. "Start from client's knowledge, teach about diet modifications, and check for learning" provides the most comprehensive intervention for this client, as it includes assessment of the client's current level of knowledge, teaching, and evaluation of the teaching. None of the other answer options includes all three of these elements.

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? A. Updating the diet orders in the client's plan of care. B. Posting the sign "NPO after midnight" over the bed. C. Obtaining written consent for the diagnostic procedure. D. Adding the diagnosis "Altered Nutrition, Less Than Required".

Answer: A Rationale: The plan of care communicates three different types of nursing care: care related to meeting basic human needs, care related to nursing diagnoses, and care that must be coordinated with medical and interdisciplinary providers. Nutrition is a basic human need. The temporary need to withhold food and fluid should be documented in the record. The other options are not the best, most direct methods for conveying this information to all who may need it.

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? A. The outcome is not observable or measurable. B. The outcome is not related to an independent nursing action. C. The statement expresses a client outcome as a nursing intervention. D. The outcome does not specify the conditions in which it will be achieved.

Answer: A Rationale: The verb in this outcome, "know," is not directly measurable or observable. The verb "demonstrate" would be more appropriate. Educating a client on how to use a nebulizer is an independent nursing action. The outcome is not expressed as a nursing intervention and conditions are not likely necessary for this outcome.

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? A. Outcome B. Intervention C. Evaluation D. Nursing diagnosis

Answer: A Rationale: This statement is an example of an expected client outcome. Outcomes answer the questions who (the client), what actions (verbalizes), under what circumstances (to the staff), how well (accurately), and when (before discharge). A nursing diagnosis, which identifies a client health problem, would include a diagnostic label, related factors, and defining characteristics. An intervention would reflect an action or treatment the nurse performs to promote client outcomes. An evaluation is not a statement but rather a process of assessing the client's response to nursing interventions.

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

Answer: B Rationale: According to Maslow's Hierarchy of Needs, physiologic needs are essential to maintain life. These needs include oxygen, water, food, temperature, elimination, sexuality, physical activity, and rest. Cutting up food and opening drink containers for the client would meet the most basic need for food. The nurse is meeting safety needs by providing a mother with the phone number for the Poison Control Center. The nurse seeking input from the client regarding preferences for a snack is showing respect to the individual and meeting self-esteem needs. When assisting the client to validate feelings regarding treatment options, the nurse is acknowledging the uniqueness of the client and respecting the client's knowledge and feelings in solving problems to attain self-actualization.

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

Answer: B Rationale: An appropriate outcome includes the client, an action verb, the circumstances by which the outcome is to be achieved, the performance criteria, and time frame. Identifying one coping strategy to try by the end of the week meets these criteria. The statement about the client learning to cope more effectively is not measurable. The statement about listing positive coping strategies and using them includes more than one behavior to evaluate, making it difficult to evaluate achievement. The statement about using relaxation is vague and not really measurable.

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? A. 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. B. 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. C. The nurse repositions the client to the client's back and documents the condition of the client's skin in the medical record. D. The nurse repositions the client to the client's back and documents the intervention in the client's record.

Answer: B Rationale: An observation of a reddened area on a client's skin that doesn't blanch after pressure is relieved is characteristic of a first-degree pressure injury. This indicates that the current nursing intervention of turning and repositioning the client every 2 hours to prevent impaired skin integrity is inadequate. The client's nursing care plan needs to be revised to reflect the new assessment finding of an actual pressure injury. Additionally, new nursing interventions need to be implemented to turn and reposition the client hourly to relieve the pressure on the trochanter ulcer and prevent the formation of new pressure injuries. Repositioning the client to the client's back, documenting the intervention, reassessing the client's right trochanter in 2 hours, and documenting the condition of the skin in the medical record all fail to update the nursing care plan and revise the interventions to a more frequent turning and repositioning schedule.

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

Answer: B Rationale: 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 nursing diagnosis will the nurse rank as the priority for premature newborn twins? A. Impaired Parenting. B. Altered Gas Exchange. C. Ineffective Thermoregulation. D. Interrupted Breastfeeding.

Answer: B Rationale: Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, circulation, or safety issues such as threats of self-harm. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. Lack of surfactant interferes with lung expansion and can reduce oxygenation in premature infants. Breastfeeding and temperature regulation are of lower importance than oxygenation. Parenting skills may be promoted when parents visit high-risk infants in the nursery.

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? A. Encourage the client to join a therapy group. B. Add the nursing diagnosis: Risk for Self-Harm. C. Tell another nurse about this client statement. D. Document that the depression has resolved.

Answer: B Rationale: Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates risk for self-harm, not resolution of the depression. The nurse will perform additional assessment and add the new nursing diagnosis to the care plan. Changing the care plan to incorporate this new data makes it the most effective for treating the client. Telling another nurse could assist in treatment, but is less formal and less effective, because the entire team needs access to this information. While group therapy may provide help, it does not address the client's current mental health status related to self-harm.

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

Answer: B Rationale: Outcomes should be specific, measurable, attainable, realistic, and timebound. Safe ambulation after several days with physical therapy meets all of these criteria. "After attending sibling classes, client will be happy about a new infant and demonstrate feeding" is incorrect because it includes more than one client behavior, one of which is not observable or measurable ("be happy"), does not include performance criteria related to how well the client is to demonstrate feeding, and has a vague time frame ("after attending sibling classes"). "By the next clinic visit, client will report taking antihypertensive medication" lacks specificity regarding how often the client should take the medication. "Client will perform complete ostomy care while bathing on the second postoperative day" is likely not attainable within the time frame specified and lacks specificity regarding care the client will provide, making it difficult for the nurse to measure the client's success.

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent? A. Performance criteria B. Verb (action) C. Subject D. Conditions

Answer: B Rationale: The action is one of the essential pieces of an outcome statement. The verb "ambulate" in this case represents the action that the client will perform and that the nurse will monitor and evaluate. The subject refers to the one who performs the action, which is always the client. The conditions are the particular circumstances in or by which the client is to achieve the outcome, such as "with the assistance of a cane" and "during a physical therapy session." The performance criteria are the expected client behaviors or other manifestations described in observable, measurable terms, such as "without incident."

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. a protocol. B. an algorithm. C. a clinical pathway. D. an order set.

Answer: C Rationale: A clinical pathway communicates the standardized, interdisciplinary plan of care for a client. Care guidelines and outcomes are specified for each day of the client's hospital stay. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. An order set is a preprinted set of provider orders that expedite the provider order process. A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of clients within the cohort. It has a broader specificity than an algorithm and allows for minimal provider flexibility by way of treatment options.

What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)? A. Nurses are responsible for reminding health care providers to implement orders. B. Nurses do not carry out health care provider-initiated interventions. C. Nurses do carry out interventions in response to a health care provider's order. D. Nurses are not legally responsible for these interventions.

Answer: C Rationale: A health care provider-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 health care provider and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding health care providers to implement orders, nurses may request a health care provider to implement an order or question an existing order by the health care provider if the nurse believes it is in the client's best interests.

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family? A. A plan with problems that are easily solved. B. A plan derived from a consensus of opinions of all staff members. C. A plan designed to support the client physically. D. A plan made in conjunction with the hospital's ethics committee.

Answer: C Rationale: An unconscious client who is unable to provide input into outcome identification depends on the nurse to make informed choices to support the client physically. This care plan would treat any life-threatening situations and act to prevent the development of unhealthy physical consequences. The nurse is in the best position to determine client needs and would not seek the opinion of all staff members or the ethics committee. The care plan would deal with all problems, not just those that are easily solved.

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's: A. medical orders. B. past medical history. C. condition. D. support system.

Answer: C Rationale: Because a person's condition changes, priorities change. Priorities are based on information collected during reassessment after recovery and assignment to the acute care setting. As the client heals these priorities can shift rapidly. The client's support system would have more of an impact on priorities of care once the client is being discharged to home, not while the client is in the acute care setting immediately after surgery. Both the client's medical orders and the client's nursing priorities change in response to the client's condition, rather than in response to one another. The client's past medical history, which doesn't change, is less likely to affect the nursing priorities of the client after surgery than the client's condition, which does change.

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? A. Choosing actions that do not solve the problem. B. Failing to update the written plan of care. C. Developing the plan without client input. D. Beginning the plan without family to help.

Answer: C Rationale: 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. There is no indication that the nurse included strategies in the plan of care that did not solve the client's problem. There is no evidence that the care plan needed to be updated or that the nurse failed to do so. Although family support can be important to achieving client outcomes, not every client outcome requires family support.

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? A. The nurse will help the client ambulate the length of the hallway once a day. B. Offer to help the client walk the length of the hallway each day. C. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. D. The client will become mobile within a 24-hour period.

Answer: C Rationale: 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, is not timebound, and is not client-centered, in that the nurse is the subject of the sentence, not the client. "Offer to help the client walk the length of the hallway each day" is a nursing intervention, not a client outcome. "The client will become mobile within a 24-hour period" is not specific or measurable.

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

Answer: C Rationale: Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where, how often, how long, or how much). The interventions should be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The health care provider does not approve and sign the interventions, because they are nursing interventions.

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

Answer: C Rationale: Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where, how often, how long, or how much). The interventions should be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The health care provider does not approve and sign the interventions, because they are nursing interventions.

The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. When completing the plan of care, which outcome is written the clearest for working with the multidisciplinary team? A. By the next clinic visit, the nurse will discuss the client's feelings around infertility. B. Client will understand the importance of follow-up laparoscopic examination. C. By discharge from the fertility clinic, the client will achieve full-term pregnancy. D. After visiting the clinic, client will indicate a desire for adoption.

Answer: C Rationale: Outcomes should be specific, measurable, attainable, realistic, and timebound. Achieving a full-term pregnancy is a specific and reasonably attainable goal. Common errors to avoid when writing outcomes are writing the outcome as a nursing intervention (e.g., the nurse will discuss the client's feelings around infertility), including more than one client behavior in a short-term outcome, using verbs that are not observable, and using verbs that are not measurable (e.g., client will understand the importance of follow-up laparoscopic examination).The other options do not directly measure resolution of the problem, they lack a time element, or do not address the issue desired (e.g., client will indicate a desire for adoption).

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

Answer: C Rationale: Outcomes should be specific, measurable, attainable, realistic, and timebound. Words such as "know" and "understand" should be avoided because they are too general to be easily measured. Other common errors to avoid are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, and using verbs that are not observable. The answer option related to the client performing dressing changes includes the verb "know," which is not an observable action. All of the other answer options meet the criteria above.

Which components must be included in an outcome? Select all that apply. A. Modifiers describing the end result. B. A description in subjective terms of the expected client behavior. C. The particular circumstances in which the outcome is to be achieved. D. A target time by which the client is expected to be able to achieve the outcome. E. The action the client will perform. F. The client or some part of the client.

Answer: C, D, E, F Rationale: Properly written outcomes contain a subject (the client or some part of the client), a verb (indicates the action the client will perform), conditions (specifies the particular circumstances by which the outcome is to be achieved), performance criteria (described in observable, measurable terms), the expected client behavior or other manifestation, and the target time. Modifiers are not included in describing the end result. The expected behavior is objective, rather than subjective.

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

Answer: D Rationale: A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nurse-initiated interventions, such as teaching, do not require a health care provider's order. A health care provider's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD). Which statement would the nurse use to teach the client about effective breathing patterns? A. "Take short and shallow breaths instead of deep breathing." B. "Do not practice pursed lip breathing, as this is a contraindication." C. "Running short distances can help you breathe better." D. "Leaning forward may help you to breathe better."

Answer: D Rationale: COPD is a chronic inflammatory disease that causes obstructed airflow from the lungs. Symptoms of COPD include difficulty breathing, wheezing, cough, and mucus production. Leaning forward helps the diaphragm move easier, allowing more air to fill the lungs. This, in turn, will help the client to breathe better. Running may lead to more difficulty breathing. Walking is a more effective intervention to educate a client with COPD. Clients with COPD should be educated about pursed lip breathing. This is the practice of relaxing the neck and shoulder muscles, breathing in through the nose for a few seconds, and then blowing the air out through pursed lips.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: A. ongoing planning. B. comprehensive planning. C. initial planning. D. discharge planning.

Answer: D Rationale: Discharge planning begins at the time of admission with the nurse teaching the client and family specific skills necessary for self-care behaviors in the home. Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning. Initial planning is done at time of admission based on the nurse's admission assessment. Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship.

Which is the primary benefit of outcome identification? A. It allows for the identification of proper diagnoses. B. It promotes an effective diagnostic process. C. It allows the nurse to evaluate the outcomes. D. It promotes the client being an active participant in care.

Answer: D Rationale: Outcome identification serves the purpose of promoting client participation. Evaluation takes place after the nurse has identified outcomes and performed interventions and thus is not the primary benefit of outcome identification. Nursing diagnosis occurs before outcome identification and thus is not its primary benefit.

The expected outcome for a client with a new diagnosis of osteoporosis is "Client will implement actions to promote safety and bone strength." Which statement by the client is the best indicator that the outcome expectations have been met? A. "I take extra calcium to make my bones stronger." B. "I removed scatter rugs from my home." C. "I turn on lights at night so I won't fall." D. "I walk daily wearing low-heeled shoes."

Answer: D Rationale: 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 diagnosis must learn appropriate actions for care. With osteoporosis the most important means to prevent further bone loss is weight-bearing activity, such as walking. While each option is appropriate for a client with osteoporosis, only one includes both components of the outcome. Activities that prevent falls, such as wearing low-heeled tie shoes, turning on lights, and removing scatter rugs, are important for safety.