ATI: Chapter 16
A nurse is caring for a client who was admitted 2 days ago following surgery. The client has finished lung sounds in the posterior bases. What is the best action by the nurse?
Encourage hourly use of the incentive spirometer
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
A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?
"Client will identify one coping strategy to try by the end of the week"
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 outcomes expectations have been met?
"I walk daily wearing low-heeled shoes"
The expected outcome for a client with a new diagnosis of diabetes mellitus is: " Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?
"I will test my glucose level before meals and use sliding scale insulin"
Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?
Altered gas exchange
A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis of "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem?
Client will alternate rest periods with exercise throughout the day
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
Psychomotor
Which action should the nurse perform during the planning step of the nursing process?
Selects nursing measures, including client education
What is an example of a nurse-initiated intervention?
Teach the client how to splint an abdominal incision when coughing and deep breathing
A nurse identifies the following diagnosis for a client with an infected leg ulcer: "Deficient Knowledge related to diminished peripheral circulation and wound care as evidenced by recurrent infected leg ulcer." Which statement would the nurse identify as addressing a cognitive outcome?
"The client states the reason for wound care measures"
A nurse is developing a client's plan of care. As part of planning interventions, the nurse incorporates a set of steps to follow as means for decision making for care. Which structured methodology is the nurse including in the plan?
Algorithm
Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer?
By discharge, the client will perform hand hygiene before and after port 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
Which statement correctly describes a nurse-initiated intervention?
Nurse-Initiated interventions are derived from the nursing diagnosis
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 the client's ADLS?
On the client's admission to the hospital
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 the statement described as?
Rationale
