240 final
The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response?
"You should always speak up if you have any questions about your care."
The nurse caring for a client with obesity would like to address the possible health problems that can develop related to obesity. To plan care for this client, what type of nursing diagnosis would the nurse formulate?
A risk nursing diagnosis
Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order?
Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners
A client reports to the nurse quitting smoking 6 months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome?
Affective
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?
The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. Which action by the nurse is most appropriate?
Ask the client if information can be given to the parent.
What would be a nursing priority when assessing a client who weighs 250 lb (112.50 kg) and stands 5 ft, 3 in (1.58 m) tall?
Assess blood pressure with a large cuff.
When planning initial care for a 16-year-old client and the client's newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next?
Assess the client's interactions with the newborn.
The nurse completed the minimum data set for a newly admitted client to a skilled nursing facility. Which action by the nurse is most appropriate?
Assess the triggers from the data.
Which client outcome requires modification?
By the end of instruction, client will know how to perform dressing changes.
A nurse is assessing a client admitted to the hospital with reporting left-sided weakness and difficulty speaking. Which documented statement best represents the data that should be collected in a nursing assessment?
Client is unable to communicate basic needs and cannot perform hygiene measures with left hand.
Which is an appropriate expected outcome for a client?
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 increase nutrition, eating 75% of meals. Client will report pain is controlled at or below 3 of 10. Client will perform dressing change independently.
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.
Which is the primary purpose of client records?
Communication
The nurse is conducting a health history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?
Continue the health history with questions focusing on respiratory function.
A client comes into the clinic for a routine postoperative visit. While the nurse is assessing the level of pain, the client states that there is occasional discomfort but that pain levels have improved daily since returning home from the hospital. What should the nurse's response be regarding the client's plan of care?
Continue the plan of care
The nurse formulates the following nursing diagnosis: Disturbed Body Image related to decreased ability to cope with surgical removal of right breast as evidenced by the client refusing to look at the surgical site and stating, "I'm ugly. My husband will no longer find me desirable." What is the etiology identified in this nursing diagnosis?
Decreased ability to cope with surgical removal of right breast
Which nursing diagnoses are stated correctly? Select all that apply.
Deficient Fluid Volume related to abnormal fluid loss Nutrition Deficit related to inability to eat a balanced diet
A client has just given birth to the client's first baby. The client reports to the nurse not knowing very much about newborns because of limited exposure to them. Which is the priority nursing diagnosis for the nurse to address prior to discharge of this client?
Deficient Knowledge
The nurse is assessing a client who was just admitted to the unit following an abdominal hysterectomy. On which assessment finding would the nurse base the priority diagnosis?
Diminished breath sounds in left lower lobe
A client has been discharged from an acute care facility with a referral for a home health nurse to make an assessment. What is the priority action by the home health nurse on the initial home visit?
Establish the client's database.
A nurse is caring for a marathon runner who collapsed while running in extremely warm weather. Upon admission, the client's temperature is 102°F (38.9°C). What is the most appropriate nursing diagnosis?
Hyperthermia
Which assessment findings would support the nursing diagnosis of Impaired Skin Integrity? Select all that apply.
Impaired mobility due to recent stroke Unable to turn in bed without assistance Uncontrolled diabetes
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.
A nursing diagnosis of Ineffective Airway Clearance has been chosen by the nurse caring for a client with respiratory problems. Which assessment data would be appropriate evidence of this diagnosis? Select all that apply.
Ineffective cough Wheezes auscultated over all lung fields Labored respirations
A teenager on life support after a diving accident has no brain wave activity. The parents tell the nurse they are sure their child will wake up soon. Which nursing diagnosis would the nurse identify to assist the parents of the child?
Interrupted Family Processes related to inability to accept their child's inevitable death as evidenced by the parents' statement that their child will wake soon
Which is a drawback to the type of documentation known as charting by exception?
Issues related to high-quality care should a negligence claim arise
A nurse is planning education about prescription medications for a client newly diagnosed with asthma. What nursing diagnosis would be most appropriate for the nurse to select?
Knowledge Deficit: Medications related to new medical diagnosis
Which are characteristics of appropriate client outcome statements? Select all that apply.
Measurable Realistic Specific
Which nursing action would be most effective in helping a client learn self-care behaviors?
Model self-care behaviors for the client.
The nurse is caring for a client for the third day in a row on the hospital unit. At the client's evening vital sign assessment, the nurse notices that the radial pulse is much slower than the apical pulse. This finding is new. What should the nurse do next?
Notify the physician of the change and document the finding.
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?
Outcome
What are specific measurable and realistic statements of goal attainment?
Outcomes
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.
A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. The cast is bivalved and capillary refill is observed at 2 seconds. What is the best modification to the care plan by the nurse?
Perform hourly neurovascular assessment.
The emergency room (ER) has a strict protocol regarding intramuscular (IM) injection technique. A nurse working in the ER has learned of a new technique to decrease pain with IM injections from the nursing literature and would like to use it. What is the most appropriate way for the nurse to implement the technique?
Petition to change the protocol based on the new evidence.
A nurse suspects that a client has a self-care deficit, but needs more data to confirm this diagnosis. What nursing diagnosis would the nurse write for this client?
Possible
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.
After learning about a client's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client's care instructions. The nurse modifies the plan of care based upon which client variable?
Psychosocial background
Before implementing any planned intervention, which action should the nurse take first?
Reassess the client to determine whether the action is needed.
Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply
Record the client's intake and output. Assist the client to the bedside commode.
A health care facility plans to evaluate and revise the plan of care for a client based on the client's health care records. The physician, dietitian, and nurse involved in the client's care are required to collate all of the information for easy access. Which style would the nurse conclude that the facility is following in order to record the client details?
SOAP charting
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 Grieving
The nurse is assessing a client with vascular dementia. As a result of this cognitive deficit, the client is unable to provide many of the data that are required. How should the nurse best proceed with this assessment?
Supplement the client's information by speaking with family or friends.
The client reports right knee pain of 6/10 on the pain scale and requests medication. The nurse assesses and flushes the intravenous site. Which type of intervention skill is the nurse using?
Technical skill
A client has returned to the clinic for a postoperative visit. The nurse reviews the plan of care and may choose to take which actions based on the client's previous responses to the current plan of care? Select all that apply.
Terminate the plan of care if the client has achieved outcomes. Modify the plan of care if the client has encountered difficulty with achieving outcomes. Continue the plan of care if more time could result in achievement of outcomes.
The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase?
Termination phase
A nurse is evaluating nursing care and client outcomes by using a retrospective evaluation. Which action would the nurse perform in this approach?
The nurse devises a postdischarge questionnaire to evaluate client satisfaction.
Which actions occur during the initial planning of client care? Select all that apply.
The nurse who performs the admission nursing history and physical assessment makes the initial plan. After the initial plan is developed, the nurse prioritizes nursing diagnoses. The nurse identifies client goals and the related nursing care in the initial plan.
Which is an example of a psychomotor outcome?
Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.
A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?
Write a narrative note in the designated nursing section.
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.
A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has:
a lack of cues, or premature closure.
Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?
altered gas exchange
Which action would the nurse perform in the assessment phase of the nursing process?
assessment
A nurse who recently graduated is performing an assessment on a client who was admitted for nausea and vomiting. During the assessment, the client reports mild chest pain. The nurse does not know whether the chest pain is related to the gastrointestinal symptoms or should be reported to the physician. Which action should the nurse perform next?
consult with another nurse
Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist?
consultation
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.
A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client?
focused
A 57-year-old client presents to the clinic with a report of abdominal pain. The client underwent a sigmoid colostomy 3 months ago for colon cancer. The client's recovery had been uneventful until 1 week ago. What type of assessment will the nurse perform?
focused assessment
For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?
inital
For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment?
initial
All of the activities listed are related to evaluation, but which evaluation activity is the priority concern for nurses?
measuring client outcome achievements with the client
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?
outcome
What are specific measurable and realistic statements of goal attainment?
outcomes
A nurse suspects that a client has a self-care deficit, but needs more data to confirm this diagnosis. What nursing diagnosis would the nurse write for this client?
possible
The primary purpose of developing expected client outcomes is to:
provide individualized care.
What dual purpose does an audit serve?
quality assurance and reimbursement
A nurse manager is discussing a nurse's social media post about an interesting client situation. The nurse states, "I didn't violate client privacy because I didn't use the client's name." What response by the nurse manager is most appropriate?
"Any information that can identify a person is considered a breach of client privacy."
A 45-year-old client has presented to the emergency department with a report of nausea and vomiting and severe pain just under the right rib cage. Which response(s) should the nurse prioritize? Select all that apply.
"Can you tell me more about the nausea and vomiting?" "I am going to apply some pressure to your abdomen to see just exactly where the pain is." "How long have your eyes had the yellow tinge?"
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?
"I walk daily wearing low-heeled shoes."
The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate?
"I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes."
A nurse is providing a change-of-shift report on a client who has had a restless night, is experiencing anxiety, and requires frequent repositioning. Which statement indicates a correct way of conducting an effective handoff at change of shift?
"The client had a good deal of anxiety last night and requested to be turned and repositioned frequently."
A nurse manager identifies a need for further instruction when a new nurse makes which statement?
"The client is always the best source for collecting data."
Which statement by a nurse best indicates an accurate understanding of the different types of assessments?
"The purpose for the assessment offers guidance for which type and how much data to collect."
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 highest priority 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
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 nurse is following a clinical pathway that guides the care of a client after knee surgery. When the nurse observes the client vomiting, it creates a deviation from the clinical pathway. What should the nurse identify this event as?
A variance
An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply.
Assisting the client with personal hygiene needs and ambulation Transporting the infant to the mother's room according to hospital policy
A nurse is taking care of a 15-year-old client with cystic fibrosis. The nurse is at the start of the shift and goes into the client's room to introduce oneself and perform a safety check. The nurse notices that the client is receiving IV fluids with potassium. When the nurse double checks to see if this is what the client is supposed to be on, the nurse notices that these fluids were supposed to have been stopped 32 hours ago. What should the nurse not do in this situation?
Attach a copy of the incident report to the chart.
The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform?
Bathe a client with stable angina who has a continuous IV infusing.
Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
Bed bath for the newly admitted client who has multiple skin lesions
The nurse manager on an orthopedic unit has determined that the nurses are not keeping the nursing diagnoses up-to-date on client care plans and, in turn, are not using the plan of care. What is a feasible approach to correcting this problem?
Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses.
The nurse receives a verbal prescription from a health care provider during an emergency situation. Which action(s) should be taken by the nurse? Select all that apply.
Read back the prescription. Record the date and time of the prescription. Include V.O. with the health care provider's name on the prescription.
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.
Which client outcomes are psychomotor outcomes? Select all that apply.
The client measures capillary blood glucose level. The client self-catheterizes using clean technique.
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.
Following a client interview, the nurse is organizing data obtained according to Gordon's functional health patterns model. Which statements reflect the focus of this model? Select all that apply.
The nurse collects data regarding the client's health perception and health management. The nurse explores the client's perception of the client's major roles and responsibilities in life. The nurse assesses and collects data on the client's elimination, activity, sleep, and sexuality.
While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of:
an inference.
The nurse, while admitting an older adult client, charts, "The client does not respond when I speak while standing on the client's right side." This statement is an example of:
cue
The nurse is assessing a client in an outpatient setting. The client states, "I do not want to live anymore. My family hates me, and I am so tired of being sick. I have a gun, and I am seriously thinking of killing myself." The client reports a 30-year heavy smoking habit and having a cough for about 6 months. Auscultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminished bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing concern for this client?
suicide attempt risk
When making an inference from the cues obtained during an assessment, it is important for the nurse to keep what in mind?
validate inferences with the client
The nurse is performing a physical assessment on a newly admitted client. During the assessment, the nurse notices the client grimacing and holding the abdomen. When the nurse asks the client whether the client is in pain, the client answers, "No." What is the best thing for the nurse to do next?
validate the data
