craven chapter 15 questions
Which is a psychomotor client goal? - By 18AUG2015, the client will value health sufficiently to quit smoking. - By 18AUG2015, the client will demonstrate improved motion in the left arm. - By 18AUG15, the client will list three foods that are low in salt. - By 18AUG2015, the client will learn three exercises designed to strengthen leg muscles.
- By 18AUG2015, the client will demonstrate improved motion in the left arm.
Why are quality-assurance programs important in nursing? -They enable nursing to be accountable for the quality of care. -They facilitate increased enrollment in educational programs. -They specify how resources are used or not used. -They allow increased retention of qualified nurses.
-They enable nursing to be accountable for the quality of care.
A nursing student received a report on his assigned clients for the clinical day. Which client should the student nurse plan to assess first? -a client who has had an appendectomy and has a temperature of 39.1 degrees C -a newly diagnosed client with diabetes who is crying and states "I do not understand how to give my insulin." - an asthma client who reports shortness of breath with a respiratory rate of 26 bpm -a client who has had a hysterectomy and reports bleeding from the surgical site
an asthma client who reports shortness of breath with a respiratory rate of 26 bpm
What is evaluated when conducting a nursing audit? -Physical environment - Policies and procedures -Client records -Client satisfaction
client records
What is evaluated when conducting a nursing audit? -Physical environment -Policies and procedures - Client records - Client satisfaction
client records
A client being treated for myasthenia gravis at home tells the nurse, "This medicine is so expensive. I have only been taking half of what the doctor ordered." How would the nurse most effectively meet this client's need? - Reinforce to the client and family the necessity of taking all medication as ordered to stabilize the client's condition. - Inform the physician of the need to prescribe a less expensive medication for the client's condition. -Collaborate with other disciplines to determine the best way to meet the client's medication requirements. - Instruct the client that some pharmaceutical companies have programs to help with medication expenses.
collaborate with other disciplines to determine the best way to meet the clients medication requirement
After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? -Document the interventions and the result. - Reassess the client for improvement in 30 minutes. - Communicate with the physician for additional orders. - Determine the client's code status in case of an emergency.
communicate with the physician for additional orders
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? -Nurse manager -Nurse care manager -Physician -Insurance company
nurse care manager
The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted? -Quality assurance -Magnet status -Peer review -Quality improvement
quality assurance
Which are areas of focus in quality improvement? Select all that apply. -Systems - Processes - Nurses -Data use - Individuals
system process data use
When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate? -"Inadequate skills" -"Great response" -"Extremely well-mannered" -"Demonstrated steps"
-"Demonstrated steps"
The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? -Remind the client that the client is responsible for the client's own health care decisions. -Ask the client whether the client is afraid that the spouse will be angry. -Ask the surgeon to wait until the client has had a chance to talk to the spouse. -Inform the surgeon that the nurse will not sign the informed consent form.
-Ask the surgeon to wait until the client has had a chance to talk to the spouse.
The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? -Assess the client's blood pressure to determine if the medication is indicated. -Determine the client's reaction to the medication in the past. -Ask the client to verbalize the purpose of the medication. -Tell the client to report any side effects experienced.
-Assess the client's blood pressure to determine if the medication is indicated.
What must occur before physician-initiated interventions can be carried out? -They must be written on the nursing plan of care. -The nurse relinquishes all responsibility for them. -Any health care provider may order them. -The physician gives a verbal or written order.
-The physician gives a verbal or written order.
Priority setting is based on the information obtained during reassessment and is used to rank nursing diagnoses. Each factor contributes to priority setting except which? -Finances of the client -The client's condition -Time and resources -Feedback from the family
finances of the client
While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? -Educational -Psychomotor -Maintenance -Surveillance
surveillance
A nurse who has been employed by the facility is scheduled for an evaluation by a group of nurses with similar education and experience. The nurse most likely is undergoing what? -Nursing monitor -Individual peer review -Process evaluation -Quality improvement
-Individual peer review
The client's expected outcome is "The client will maintain skin integrity by discharge." Which measure is best in evaluating the outcome? -The client's ability to reposition self in bed -The presence of a pressure-relieving mattress on the bed -The percent intake of a diet high in protein -The condition of the skin over bony prominences
-The condition of the skin over bony prominences
An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Which is the nurse's most appropriate action? -Insert the urinary catheter as ordered to relieve the urinary retention. -Reassess whether the client still needs the urinary catheter. -Instruct the client that the catheter is essential to check for urinary retention. -Inform the client that the catheter will no longer be necessary.
Reassess whether the client still needs the urinary catheter.
A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care? -Another nurse manager -Another registered nurse with critical care certification -One of the staff critical care physicians -Another staff nurse from the medical-surgical unit
another registered nurse with critical care ceritifcation
A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care? -Another nurse manager -Another registered nurse with critical care certification -One of the staff critical care physicians -Another staff nurse from the medical-surgical unit
-Another registered nurse with critical care certification
Which nurse is using criteria to determine expected standards of performance? -The nurse manager provides the staff nurse feedback regarding job performance for the previous year. -The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. -The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. -The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.
-The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.
Which nursing action reflects ANA and CNA Standards of Practice regarding implementation? -The nurse collects data from the client and family. -The nurse prioritizes the client's health problems. -The nurse monitors the client's response to interventions. -The nurse uses community resources to implement the plan.
-The nurse uses community resources to implement the plan.
Which examples of nursing actions involve direct care of the client? Select all that apply. -A nurse counsels a young family who is interested in natural family planning. -A nurse massages the back of a client while performing a skin assessment. - A nurse arranges for a consultation for a client who has no health insurance. - A nurse helps a client in hospice fill out a living will form. - A nurse arranges for physical therapy for a client who had a stroke.
A nurse counsels a young family who is interested in natural family planning. A nurse massages the back of a client while performing a skin assessment. A nurse helps a client in hospice fill out a living will form.
An older adult client with a diagnosis of pneumonia is producing large amounts of secretions with his cough and is occasionally gurgling when he breathes. The nurse has responded by increasing the height of the client's bed and suctioning the client's mouth. The nurse has most likely performed which of the following? -A dependent nursing action -An interdependent nursing action -A restricted nursing action -An independent nursing action
An independent nursing action
The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect? -Assessment -Outcome identification -Implementation -Evaluation
evaluation
The emergency room nurse is performing an initial assessment of a new client who presents with severe dizziness. The client reports a medical history of hypertension, gout, and migraine headaches. Which step should the nurse take first in the comprehensive assessment? -Perform vital signs and blood glucose level. -DIscuss the need to change positions slowly, especially when moving from sitting to standing. -Perform a full review of systems. - Initiate an intravenous line and administer 500mL of normal saline.
perform vital signs and blood glucose levels
A nurse follows set guidelines for administering pain medication to clients in a critical care unit. This nurse's authority to initiate actions that normally require the order or supervision of a physician is termed: -protocols. -nursing interventions. -collaborative orders. - standing orders.
standing orders
While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? - Educational - Psychomotor -Maintenance - Surveillance
surveillance
Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply. -Record the client's intake and output. -Assess the client's need for education. -Assist the client to the bedside commode. -Assess the client's risk for pressure injuries. -Administer routine oral medications.
-Record the client's intake and output. -Assist the client to the bedside commode.
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care? -Nurse manager -Nurse case manager -Physician -Insurance company
nurse case manager
Mr. J. is a 56-year-old man status post admission for a myocardial infarction and coronary artery bypass graft. He is preparing to go home tomorrow. Mr. J. expresses that he feels unprepared to cook heart-healthy foods. The nurse sits with Mr. J. and reviews the heart-healthy nutrition plan, asking him to identify which foods would be appropriate for him to eat. What type of nursing intervention is the nurse engaging in? -Supervisory intervention -Educational intervention -Coordinating intervention -Supportive intervention
-Supervisory intervention
A nursing student received a report on his assigned clients for the clinical day. Which client should the student nurse plan to assess first? -a client who has had an appendectomy and has a temperature of 39.1 degrees C -a newly diagnosed client with diabetes who is crying and states "I do not understand how to give my insulin." -an asthma client who reports shortness of breath with a respiratory rate of 26 bpm - a client who has had a hysterectomy and reports bleeding from the surgical site
-an asthma client who reports shortness of breath with a respiratory rate of 26 bpm
A client being treated with chemotherapy for breast cancer tells the nurse that she no longer wants to receive the medication because of the overwhelming nausea and vomiting. What is the best response by the nurse? -"I am going to have to tell the health care provider that you are refusing treatment." -"Are you aware of what will happen to you if you stop taking the chemotherapy?" -"I will consult with the health care provider to see how the nausea and vomiting can be prevented." -"I am going to discuss this with your family members."
"I will consult with the health care provider to see how the nausea and vomiting can be prevented."
A client with a new diagnosis of diabetes will be discharged on insulin therapy. Which client psychomotor outcome does the nurse expect after client education? -The client demonstrates administration of insulin. -The client reports testing blood sugar before meals. -The client identifies signs and symptoms of hypoglycemia. -The client identifies correct insulin injection sites.
-The client demonstrates administration of insulin.
The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan? -Create a new nursing diagnosis to reflect new goals. -Evaluate the use of current pain relief measures. -Request a stronger analgesic from the provider. -Provide additional relief with non-pharmacologic measures.
Evaluate the use of current pain relief measures.
Which nurse is using criteria to determine expected standards of performance? -The nurse manager provides the staff nurse feedback regarding job performance for the previous year. -The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. -The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. -The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.
The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.
Why are quality-assurance programs important in nursing? -They facilitate increased enrollment in educational programs. -They specify how resources are used or not used. -They allow increased retention of qualified nurses. -They enable nursing to be accountable for the quality of care.
They enable nursing to be accountable for the quality of care.
After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action? -Document the interventions and the result. -Reassess the client for improvement in 30 minutes. - Communicate with the physician for additional orders. -Determine the client's code status in case of an emergency.
communicate with the physician for additional orders
A nurse caring for an older adult client who has dementia observes another nurse putting restraints on the client without a physician's order. The client is agitated and not cooperating. What would be the best initial action of the first nurse in this situation? -Report the nurse applying the restraints to the supervisor. - File an incident report and have the second nurse sign it. - Confront the nurse and explain how this could be dangerous for the client. -Contact the physician for an order for the restraints.
confront the nurse and explain how this could be dangerous for the client
A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first? - Identify changes from the baseline. - Ensure physician approval for the education plan. -Determine the client's willingness to follow the regimen. - Instruct the unlicensed assistive personnel on what to teach the client.
determine the clients willingness to follow the regimen
A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first? -Determine the client's willingness to follow the regimen. -Identify changes from the baseline. -Ensure physician approval for the education plan. - Instruct the unlicensed assistive personnel on what to teach the client.
determine the clients willingness to follow the regimen
A client has a nursing diagnosis of Possible Spiritual Distress. What is the most appropriate nursing intervention? -Seek out the client's pastor for help. - Discuss spirituality with the client. - Offer to pray with the client. - Leave the client alone for privacy.
discuss spirituality with the client
A hospital is evaluating its policies and procedures. What type of evaluation is the hospital conducting? -Outcome -Process -Quality -Structure
structure
The home health care nurse has been working with the client with chronic obstructive pulmonary disease (COPD) discharged to home 3 weeks ago. When evaluating the client's progress, the nurse recognizes that: -nursing diagnoses rarely change in the immediate discharge period. -if the client fails to achieve expected outcomes, a new care plan will need to be developed. -home health care nurses use different evaluation skills compared with hospital nurses. -it may be necessary to adjust the time frame for achieving client outcomes.
it may be necessary to adjust the time frame for achieving client outcomes.
A plan of care for a client with a low potassium level includes providing information about the effect of medications and about dietary intake of foods high in potassium. How would a nurse measure achievement of an outcome for this plan? -Physical assessment -Health history -Laboratory data -Client statements
laboratory data
The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? -The client calls for assistance to get out of bed. -The client is free of falls. -The client is taught safety precautions. -The client verbalizes risks for injury.
the client is free of falls
Which nurse is using criteria to determine expected standards of performance? -The nurse manager provides the staff nurse feedback regarding job performance for the previous year. -The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. -The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. - The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.
the new graduate nurse consults the police and procedures of the institution prior to skill implementation
Based upon chart reviews, it is determined that documentation on a telemetry unit is inadequate and incomplete. What is an appropriate nursing response to this problem? - The nurse educator reviews the legal reasons for careful and complete documentation. - The nurse manager mandates hourly documentation for each client. -The registered nurse delegates documentation to unlicensed assistive personnel (UAP). - The hospital's legal department provides a written warning to nurses with poor documentation skills.
the nurse educator reviews the legal reasons for careful and complete documentation
Which action by the nurse is an example of peer review? -The nurse seeks feedback from the nurse manager regarding job performance for the previous year. - The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family's response to the nurse's education. - The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. - The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.
the nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation
The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management? - Effectiveness of intervention including current pain scale, time frame, and client self-report. -Ability of pain medication to be decreased over a designated period of time along with the time frame to be medication free. -Length of time between requests for pain medication along with pain scale rating and the amount of medication provided. - What techniques have been used to reduce pain outside of pharmacologic modalities as well as how often they are being practiced.
- Effectiveness of intervention including current pain scale, time frame, and client self-report.
Before implementing any planned intervention, which action should the nurse take first? -Have the required equipment ready for use. - Reassess the client to determine whether the action is needed. - Ask the client whether this is a good time to do the intervention. -Record the planned intervention in the client's medical record.
- Reassess the client to determine whether the action is needed.
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? -"I will report your concerns to the nurse manager." -"I will discuss your concerns with the night nurse." -"You should always speak up if you have any questions about your care." -"You always have the right to refuse any medication or treatment."
-"You should always speak up if you have any questions about your care."
A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? -A client with a high fever receiving intravenous fluids, antibiotics, and oxygen -An older adult with pneumonia who is being discharged to the son's home tomorrow - A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall -An adult client who is being treated for kidney stones
-A client with a high fever receiving intravenous fluids, antibiotics, and oxygen
The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse's priority intervention? -Inform the client when ambulation is scheduled next. -Assess the client's response to the ambulation. -Discuss the client's feelings about the illness. -Document the client's ambulation.
-Assess the client's response to the ambulation.
A client's plan of care identifies the following goal: The client will demonstrate correct technique to administer insulin to control his blood glucose levels by discharge. What would the nurse use to determine that the client's goal has been met? Select all that apply. -Client self-administers insulin into outer thigh. -Client states the need to apply pressure to the injection site. - Client demonstrates drawing up correct amount of prescribed insulin in syringe. -Client states that he is a little uncomfortable injecting himself. - Client requires assistance in locating appropriate injection site.
-Client self-administers insulin into outer thigh. -Client states the need to apply pressure to the injection site. - Client demonstrates drawing up correct amount of prescribed insulin in syringe.
Which action is appropriate when evaluating a client's responses to a plan of care? -Reinforce the plan of care when each expected outcome is achieved. -Terminate the plan if there are difficulties achieving the goals/outcomes. - Terminate the plan of care upon client discharge. -Continue the plan of care if more time is needed to achieve the goals/outcomes.
-Continue the plan of care if more time is needed to achieve the goals/outcomes.
Which are benefits of using the nursing intervention classification (NIC) system for the development of interventions? Select all that apply. -Creation of a standardized language - Assistance in determining the cost of services that nurses provide -Demonstration of the impact of nurses - Justifcation of the productivity of the nursing staff - Determination of which nursing actions the nurse may delegate
-Creation of a standardized language -Assistance in determining the cost of services that nurses provide - Demonstration of the impact of nurses
A nurse has developed a plan of care for a client whose spouse recently died. The nurse assigned the client a nursing diagnosis of: Risk for Loneliness. When the nurse is evaluating the plan, the client tells the nurse new information about having an active social life and being satisfied with social activities. What should the nurse do next? -Continue with the plan. -Delete the nursing diagnosis. -Tell the client that the client is lonely. -Adjust the time criteria.
-Delete the nursing diagnosis.
The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management? - Ability of pain medication to be decreased over a designated period of time along with the time frame to be medication free. -Length of time between requests for pain medication along with pain scale rating and the amount of medication provided. - What techniques have been used to reduce pain outside of pharmacologic modalities as well as how often they are being practiced. -Effectiveness of intervention including current pain scale, time frame, and client self-report.
-Effectiveness of intervention including current pain scale, time frame, and client self-report.
The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management? -Ability of pain medication to be decreased over a designated period of time along with the time frame to be medication free. -Length of time between requests for pain medication along with pain scale rating and the amount of medication provided. -Effectiveness of intervention including current pain scale, time frame, and client self-report. -What techniques have been used to reduce pain outside of pharmacologic modalities as well as how often they are being practiced.
-Effectiveness of intervention including current pain scale, time frame, and client self-report.
The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What parameters would the nurse document to support evaluation of pain management? -Ability of pain medication to be decreased over a designated period of time along with the time frame to be medication free. -Length of time between requests for pain medication along with pain scale rating and the amount of medication provided. -What techniques have been used to reduce pain outside of pharmacologic modalities as well as how often they are being practiced. -Effectiveness of intervention including current pain scale, time frame, and client self-report.
-Effectiveness of intervention including current pain scale, time frame, and client self-report.
The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention? -Perform all care activities for the client to facilitate rest. -Teach the family to anticipate the client's needs to care for the client. -Encourage the client to provide as much self-care as possible. -Arrange with the nurse case manager for an early discharge.
-Encourage the client to provide as much self-care as possible.
The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time? -Providing medication for agitation -Repositioning to prevent pressure injuries -Ensuring that the endotracheal tube is secure -Changing the dressing to prevent infection
-Ensuring that the endotracheal tube is secure
A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? -Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. -Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. - Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure. -Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.
-Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization.
A client is receiving care on a rehabilitative medicine unit during recovery from a stroke. The client voices frustration that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration? -Facilitate communication between the different professionals and attempt to coordinate care. - Educate the client about the unique scope and focus of each member of the health care team. - Modify the client's plan of care to better reflect the commonalities between the different disciplines. -Arrange for all professionals to perform bedside assessments and interventions simultaneously, rather than individually.
-Facilitate communication between the different professionals and attempt to coordinate care.
A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem? -Reprimand the nursing personnel responsible for the clients when the falls occurred. -Investigate the circumstances that contributed to client falls. -Institute a new policy on the prevention of client falls on the unit. -Determine if client falls have increased on other units in the hospital.
-Investigate the circumstances that contributed to client falls.
The nurse is reviewing the charts of clients admitted to the hospital for stroke and identifying complications related to nursing care that occurred during hospitalization. The nurse is engaged in which type of activity? -Peer review -Micromanagement -Nursing audit - Concurrent evaluation
-Nursing audit
A nurse is caring for a client in the critical care unit. While preparing for the client's transfer to the telemetry unit, which would the nurse implement to facilitate successful handoff? -Deliver the client with all the needed discharge and chart notes to the unit. -Phone orders to the unlicensed assistive personnel at the new unit and send the chart notes with the client for the nurse. -Phone orders to the receiving nurse in the new unit and submit the chart with notes and reports via online submission. -Call for discharge-transfer service to deliver the client with all chart notes and laboratory and other test results to the new unit.
-Phone orders to the receiving nurse in the new unit and submit the chart with notes and reports via online submission.
A client with suspected metastases of her breast cancer is extremely anxious while she awaits the results of her latest computed tomography (CT) scan. The nurse has administered a sublingual benzodiazepine to treat her acute anxiety and has engaged the client in a therapeutic dialogue in an effort to alleviate her stress. Which of the following Nursing Interventions Classification (NIC) domains has the nurse utilized? -Safety; Physiologic: Basic -Safety; Health System -Physiologic: Complex; Behavioral -Behavioral; Physiologic: Basic
-Physiologic: Complex; Behavioral
When the nurse enters the room to assess a client's vital signs, the client insists that the nurse perform handwashing. What is the nurse's most appropriate action? -Inform the client that it is not necessary to wash hands before vital signs. -Reassure the client that the nurse knows when to perform hand hygiene. -Praise the client for taking an active role in the client's care. -Tell the client that gloves are required for this procedure.
-Praise the client for taking an active role in the client's care.
A client with hypertension being seen for follow-up care has a blood pressure of 160/100 mm Hg. The client reports following the treatment regimen closely and that blood pressure readings have been elevated for the last 2 weeks. What is the nurse's most appropriate action? -Reinforce the instructions for the treatment regimen to the client. -Interview the family to determine if the client is giving accurate information. -Report the findings to the physician for further plans. -Inform the client that the blood pressure medication will have to be changed.
-Report the findings to the physician for further plans.
Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? -Revise the care plan to allow the client to ambulate to the bathroom independently. -Continue assisting the client to the bathroom to ensure the client's safety. -Consult with the physical therapist to determine the client's ability. -Instruct the client's family to assist the client to ambulate to the bathroom.
-Revise the care plan to allow the client to ambulate to the bathroom independently.
What are the advantages of using standard Nursing Interventions Classifications (NIC)? Select all that apply. -Limiting the amount of reimbursement allowed for nursing services -Teaching decision making -Allocating nursing resources -Allowing the use of multiple systems of nomenclature - Developing information systems -Communicating nursing to non-nurses
-Teaching decision making - Allocating nursing resources - Developing information systems - Communicating nursing to non-nurses
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. - Explain the plan of care to significant others and advise them of the expectation that the client will achieve outcomes within a reasonable amount of time. -Continue the plan of care if more time could result in achievement of outcomes.
-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.
A nurse is caring for a postoperative client after a scheduled ileostomy. Which action by the nurse reflects an effective cognitive outcome? -The client demonstrates how to empty the ileostomy bag. -The client plans to attend the hospital's ileostomy/colostomy support group after discharge. -The client is able to eat a soft diet 3 days after surgery. -The client identifies three strategies for minimizing leakage of an ileostomy bag.
-The client identifies three strategies for minimizing leakage of an ileostomy bag.
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. -Initial assessment of the mother after birth of the infant -Assisting the client with personal hygiene needs and ambulation - Assisting and teaching the client to breastfeed the infant - Providing routine discharge instructions related to infant care -Transporting the infant to the mother's room according to hospital policy
-Transporting the infant to the mother's room according to hospital policy -Assisting the client with personal hygiene needs and ambulation
A nurse is changing a sterile pressure injury dressing based on an established protocol. What does this mean? -The nurse is using critical thinking to implement the dressing change. -The client has specified how the dressing should be changed. -Written plans are developed that specify nursing activities for this skill. -The physician verbally requested specific steps of the dressing change.
-Written plans are developed that specify nursing activities for this skill.
The nurse is evaluating the client's actual outcomes with the expected outcomes detailed in the nursing care plan. Which is an unlikely explanation as to why the client may not have achieved the expected outcomes? -The client needs additional time for outcome achievement. - The nurse failed to individualize the interventions to the client. -The nursing diagnosis was supported by the assessment data. -The outcome statement was vague regarding discharge needs.
the nursing diagnosis was supported by the assessment data
Which nursing action would be most effective in helping a client learn self-care behaviors? -Check with the client to ensure that personal self-care goals are being met. -Model self-care behaviors for the client. -Collect data on the number of self-care activities the client has performed that day. - Ask client to discuss the client's goals for the day at the start of the shift.
model self care behaviors of the client
The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, "I am not ready to deal with this now. I am feeling overwhelmed." What is the nurse's most appropriate action? -Continue the education and remind the client that it is essential to learn self-care. -Medicate the client for anxiety and continue the education later. -Discontinue the education and attempt at another time. -Discontinue the education and ask the client for permission to teach a family member.
discontinue the education and attempt at another time
The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond? - Review with the client the risks and benefits of surgery. -Ask the client to discuss the decision with family members. - Discuss with the client the reasons for declining surgery. - Notify the physician of the client's refusal.
discuss with the client the reasons for declining surgery
A nurse is catheterizing a client. Which scenario demonstrates steps the nurse would take to ensure client respect and privacy? -Verify the client's identifiable information, explain the procedure to the family, and pull the privacy curtain to allow the client to feel comfortable in having family close by. -Explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catheterization. -Ask family members to leave the room briefly, close the door, and ask the client if he or she would like a sheet to cover oneself. -Bring in another nurse to provide support and prevent questionable behaviors, explain the procedure to the client, and close the door and privacy curtain prior to beginning the procedure.
explain the procedure to the client, close the door to the room, and cover all areas of the client, only exposing the area for catherization
A client is receiving care on a rehabilitative medicine unit during recovery from a stroke. The client voices frustration that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration? -Educate the client about the unique scope and focus of each member of the health care team. -Modify the client's plan of care to better reflect the commonalities between the different disciplines. - Arrange for all professionals to perform bedside assessments and interventions simultaneously, rather than individually. -Facilitate communication between the different professionals and attempt to coordinate care.
facilitate communication between the different professionals and attempt to coordinate care
A plan of care for a client with a low potassium level includes providing information about the effect of medications and about dietary intake of foods high in potassium. How would a nurse measure achievement of an outcome for this plan? -Physical assessment -Health history -Laboratory data -Client statements
laboratory data
The nurse implements coordinating interventions for a client who is admitted to the health care facility for eye surgery. What would the nurse most likely do? -provide group therapy - make referrals for follow-up care -role model social skills -delegate specific aspects of care
make referrals for follow up care
The nursing staff on a hospital unit uses peer review to improve professional performance. Who performs the review? -nurses -unit managers -clients -visitors
nurses
The 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, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining? -Process -Structure -Outcome -Cost-effectiveness
outcome
While assessing a postoperative client, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000/µL (12 × 109/L), and the client's abdominal wound has a 0.5-in (1.25-cm) gap at the lower end with yellow-green discharge. The nurse would prioritize which intervention? -Begin intravenous antibiotics. -Contact the health care provider. -Apply topical antibiotic ointment. -Place the client on contact isolation.
place the client on contact isolation
The nurse participates in a quality assurance program and reviews evaluation data for the previous month. The data indicates a nursing plan was developed within 8 hours of admission for 97% of all admissions. The nurse recognizes this as which type of evaluation? -Design evaluation -Outcome evaluation -Structure evaluation -Process evaluation
process evaluation
The client is about to have blood drawn before seeing the health care provider. The spouse, while smiling and holding the client's hand, states, "Here comes the blood sucker. It is going to hurt bad." This statement is an example of which types of intervention? Select all that apply. -Psychosocial -Supportive -Physical -Coordinating - Technical
psychosocial supportive physical
The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted? -Quality assurance -Magnet status -Peer review -Quality improvement
quality assurance
A nurse finds that a client who was admitted with pancreatitis and has been stable seems to be unusually quiet and withdrawn. Which intervention would be most appropriate at this time? -Leave the client alone. -Reassess the client for pain. -Provide diversional activity. -Encourage the client's family to visit.
reassess the client for pain
Which action should the nurse take when client data indicate that the stated goals have not been achieved? -Collect more data for the database. -Review each preceding step of the nursing process. - Implement a standardized plan of care. -Change the nursing orders.
review each preceding step of the nursing process
While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? -Educational -Psychomotor -Maintenance -Surveillance
surveillance
After a month of pursuing a new nutiritonal and exercise plan to lose weight, a client has lost 2 lb (0.90 kg) of the 5 lb/month (2.25 kg/month) goal. How should the nurse alter the plan of care in response to this new data? -The nurse should not alter the plan of care. -The nurse should change the diet. -The nurse should delete the nursing diagnosis. -The nurse should modify the time criteria.
the nurse should modify the time criteria
A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? -To implement evidence-based practice -To ensure the order follows hospital policy -To be sure interventions are individualized -To be sure the intervention is safe
to be sure the intervention is safe
A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? -To implement evidence-based practice -To ensure the order follows hospital policy -To be sure interventions are individualized -To be sure the intervention is safe
to be sure the intervention is safe
