Fundamentals final ch 13- 20 prep U

ch 17 The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? A) "I must conduct research to validate the usefulness of my nursing interventions." B) "I can learn about evidence-based practice by reading professional nursing journals." C) "Nursing interventions should be supported by a sound scientific rationale." D) "The Agency for Healthcare Research and Quality is a resource for evidence-based practice."

"I must conduct research to validate the usefulness of my nursing interventions."

ch 14 Which statement by a nurse best indicates an accurate understanding of the different types of assessments? select all that apply "It is up to the nurse to decide which assessment to perform." "How much time the nurse has and how the client is feeling determine which type of assessment to perform." "The purpose for the assessment offers guidance for which type and how much data to collect." "The physician informs the nurse of which type of assessment to perform for each client."

"The purpose for the assessment offers guidance for which type and how much data to collect."

ch 19 A nurse helps a client who has cystic fibrosis prepare a stand-alone personal health record. Which statement by the nurse best explains this type of information? A) "You can fill in information from your own records and store it on your computer or the Internet." B) "You can link your record to a specific health care organization's electronic health record system." C) "Your health care provider is obligated to read your personal health record and share it with your insurance provider." D) "Your entire health care team may access and securely share your vital medical information electronically."

"You can fill in information from your own records and store it on your computer or the Internet."

CH 15 A client is caring for the client's mother-in-law, who is an older adult who requires assistance with peforming activities of daily living. Which statement by the client would lead the nurse to make a nursing diagnosis of Caregiver Role Strain? A) "I just don't have time to take a shower." B) "I feel great but wish that I could get more sleep." C) "My mother-in-law and I go for a walk daily." D) "My mother-in-law makes dinner on Tuesdays, and I cannot stand her cooking."

A) "I just don't have time to take a shower."

A nurse manager identifies a need for further instruction when a new nurse makes which statement? A) "The client is always the best source for collecting data." B)"The client is usually the best source for collecting data." C)"Family members are a good source of data when the client is a young child." D) "Caregivers can be a helpful source of data when the client has a limited capacity for information."

A) "The client is always the best source for collecting data."

ch 19 The nurse is documenting an assessment that was completed at 9:30 p.m. The facility uses military time for documentation. What entry should the nurse make for the time care was given? A) 2130 B) 0930 C) 930 p.m. D) 1930

A) 2130

ch 16 For which client would a standardized plan of care most likely be appropriate? A) A client who was admitted for shortness of breath and who has been diagnosed with pneumonia B) A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy C) A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem D) A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident

A) A client who was admitted for shortness of breath and who has been diagnosed with pneumonia Standardized care plans are most appropriate for clients who are experiencing a common and specific health problem, such as pneumonia. Clients with multiple pathologies or symptoms of unknown etiology are unlikely to have their unique needs reflected in a standardized care plan.

CH 15 A nurse is treating a client with congestive heart failure. The client reports having difficulty walking up the stairs at home and barely being able to walk to the store. Which is an accurate actual nursing diagnosis for this client? A) Activity Intolerance related to congestive heart failure as evidenced by inability to walk up and down stairs B) Activity Intolerance as evidenced by inability to walk up and down stairs and inability to walk to the store C) Noncompliance with new diagnosis of congestive heart failure D) Risk for Impaired Coping related to congestive heart failure

A) Activity Intolerance related to congestive heart failure as evidenced by inability to walk up and down stairs

CH 15 A 19-year-old college basketball player is being evaluated for injuries after a skiing accident. The nurse determines that the client has a pulse of 52 beats/min. What would be the most appropriate way for the nurse to determine the significance of the client's heart rate? A) Ask the client whether the heart rate is normal for the client. B) Compare the client's heart rate to that another teenaged client. C) Have another nurse reassess the heart rate for accuracy. D) Determine whether the client has any risk factors for cardiac disease.

A) Ask the client whether the heart rate is normal for the client. A well-conditioned athlete is very likely to have a pulse rate lower than normal at rest. The key assessment is to compare the current heart rate with the client's baseline. Asking the client would be a simple way of confirming it.

CH15 A homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly soiled. What nursing diagnosis would be most appropriate for the nurse to identify? A) Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor B) Homelessness Syndrome related to lack of housing as evidenced by visibly soiled clothing C) Inadequate Hygiene related to homelessness as evidenced by client's stink D) Impaired Impulse Control related to poor socioeconomic conditions as evidenced by visibly soiled clothing

A) Bathing Self-care Deficit related to lack of access to bathing facilities as evidenced by a strong body odor

ch 19 A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? A) Calling the client information desk to find out the room number of the family member B) Finding the emergency medical technicians who transported the family members and inquiring about the injuries C) Asking the emergency department nurse for information on the family member D) Accessing the electronic health record of the family member to find out extent of injury

A) Calling the client information desk to find out the room number of the family member Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

ch 13 Which activity is the clearest example of the evaluation step in the nursing process? A) Checking the client's blood pressure 30 minutes after administering captopril B) Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading C) Taking a client's blood pressure on both arms at the beginning of a shift D) Recognizing that the client's blood pressure of 172/101 is an abnormal finding

A) Checking the client's blood pressure 30 minutes after administering captopril

CH 16 A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem? A) Client will alternate rest periods with exercise throughout the day. B) Client will increase protein intake in small frequent meals. C) Client will use oxygen by nasal cannula when short of breath. D) Client will consistently perform pulmonary exercises.

A) Client will alternate rest periods with exercise throughout the day.

CH 16 A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem? A) Client will not leave the premises without a caregiver. B) Client will wear an ID bracelet with name and contact information. C) Client will identify landmarks that indicate location of home. D) Client will consistently return to the police station when lost.

A) Client will not leave the premises without a caregiver.

ch 17 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? A) Collaborate with other disciplines to determine the best way to meet the client's medication requirements. B) Reinforce to the client and family the necessity of taking all medication as ordered to stabilize the client's condition. C) Inform the physician of the need to prescribe a less expensive medication for the client's condition. D) Instruct the client that some pharmaceutical companies have programs to help with medication expenses.

A) Collaborate with other disciplines to determine the best way to meet the client's medication requirements.

CH 15 While developing a plan of care for a client, what should the nurse do before selecting a nursing diagnosis? A) Collect client subjective and objective data. B) Establish short- and long-term client goals. C) Perform a focused assessment related to the reason for admission. D) Verify the primary care provider's written orders.

A) Collect client subjective and objective data.

ch 14 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? A) Continue the health history with questions focusing on respiratory function. B) Consult with other members of the health care team about the conflicting client information. C) Prioritize documentation of objective data collected in the examination while avoiding any mention of the discrepancy. D) Ask significant family members about the client's usual breathing pattern at home.

A) Continue the health history with questions focusing on respiratory function.

ch 20 A nurse is documenting a client's vital signs, height, and weight in the electronic health record. Applying the framework for informatics practice, the nurse would identify these values as which component of the framework? A) Data B) Information C) Knowledge D) Wisdom

A) Data

ch 13 Which action exemplifies the purpose of evaluation in the nursing process? A) Decide whether to continue, modify, or terminate client care. B) Develop a prioritized list of nursing diagnoses. C) Develop an individualized plan of client care. D) Determine the client's health status, self-care ability, and need for nursing.

A) Decide whether to continue, modify, or terminate client care.

ch 19 According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? A) Documentation B) Accreditation C) Psychomotor skills D) Clinical judgment

A) Documentation

ch 16 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) Encourage hourly use of the incentive spirometer. B) Promote oral fluid intake between meals. C) Provide oral pain medication before ambulation. D) Reassess in 4 hours and document the findings.

A) Encourage hourly use of the incentive spirometer.

ch 19 An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. Which response by the nurse is most appropriate? A) Explain the reason why information cannot be disclosed. B) Verify the insurance coverage before giving information. C) Refer the parent to the physician providing care. D) Mediate a meeting between the parent and client.

A) Explain the reason why information cannot be disclosed.

ch 20 An informatics nurse specialist is recommending the addition of an alert system tool to the facility's patient portal. The tool would be designed to send alerts to the client to schedule routine screenings and immunizations. This recommendation most likely reflects which ANA informatics competency? A) Health teaching and health promotion B) Consultation C) Quality of practice D) Leadership

A) Health teaching and health promotion

CH 15 When developing a nursing diagnosis for a client, which should the nurse do first? A) Identify the significant data B) Cluster the cues C) Synthesize cue clusters D) Validate the diagnosis

A) Identify the significant data

CH 16 A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? A) Narcotic analgesic to treat pain B) Septic workup due to blood pressure and heart rate elevation C) Isolation for suspected respiratory illness D) Acetaminophen to treat pain and fever

A) Narcotic analgesic to treat pain

ch 13 What is the most beneficial use of the nursing process in addressing the needs of the client? A) Provides a universally applicable framework for nursing activities B) Allows the nurse to determine a medical diagnosis for the client C) Allows student nurses to work on assignments D) Targets desired outcomes for particular illnesses, procedures, or conditions

A) Provides a universally applicable framework for nursing activities

ch 20 An informatics nurse is reading a journal article about standard terminologies. The nurse demonstrates a need to reread the article when identifying which example as reflecting a standard terminology? A) PubMed B) Nursing Interventions Classification C) Clinical Care Classification System D) NANDA Nursing Diagnoses

A) PubMed Standard terminologies include NANDA-I nursing diagnoses, Nursing Interventions Classification, and Clinical Care Classification System. PubMed is a database of peer-reviewed journals that can be used for a literature search.

ch 17 A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment? A) Recognize the nurse's own limitations and ask for another nurse to be assigned. B) Recognize that the nurse may be faced with this issue again and care for the client. C) Recognize the nurse's own limitations and ask another nurse to assist if the nurse becomes too emotional. D) Recognize the issue and care for the client to the best of the nurse's ability.

A) Recognize the nurse's own limitations and ask for another nurse to be assigned.

CH 15 An older adult client's venous ulcer has become foul-smelling after the client began using strips of a sheet to dress the wound due to running out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this client's circumstances? A) Risk for Infection related to knowledge deficit B) Acute Confusion related to appropriate wound care C) Knowledge Deficit due to risk for infection D) Risk for sepsis related to local infection.

A) Risk for Infection related to knowledge deficit

CH 15 A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern? A) Risk for Powerlessness B) Disturbed Body Image C) Impaired Comfort D) Risk for Suicide

A) Risk for Powerlessness

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis? A) Risk for falls B) Hypertension C) Congestive heart failure D) Pneumonia

A) Risk for falls

ch 19 When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data, in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nurse implementing? A) SOAP charting B) PIE charting C) FOCUS charting D) narrative charting

A) SOAP charting

CH 16 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? A) Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. B) Assist the client to put on the clothing that goes over the operated leg. C) Tell the client's family to bring in clothes a size larger to make dressing easier. D) Arrange for the social worker to schedule home health care with discharge planning.

A) Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. Nursing interventions designed to promote client independence will implement methods for the client to perform a skill without help. Assistive devices for eating, bathing, dressing, and ambulation are common tools to develop client independence. The other options do not directly promote independent activity.

CH 16 A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client? A) The client will ambulate with assistance by the nurse to a bedside chair. B) The client will return to performing activities of daily living. C) The client will walk 1 mile briskly five times per week. D) The client will not undergo repeat surgery

A) The client will ambulate with assistance by the nurse to a bedside chair.

c 16 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? A) The client will ambulate with the assistance of a walker without falling within the next 4 hours. B) Physical therapy will be consulted to assist the client with ambulation. C) The client will ambulate to the restroom 3 times this shift. D) The client will ambulate with the assistance of a walker sometime today.

A) The client will ambulate with the assistance of a walker without falling within the next 4 hours.

ch 13 Self-evaluation is a method that nurses use to promote their own development and to grow in confidence in their nursing roles. This process is referred to as: A) assessment of oneself. B) promoting the nurse's self-esteem. C) learning from mistakes. D) reflective practice.

A) assessment of oneself.

ch 14 During the initial assessment of a newly admitted client, the nurse has clustered data as follows: range of motion with gait, bowel sounds with usual elimination pattern, and chest sounds with respiratory rate. The nurse is most likely organizing assessment data according to: A) body systems. B) functional health patterns. C) human response patterns. D) human needs.

A) body systems.

ch 13 The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately states, "This client is getting worse." This is an example of the experienced nurse using: A) intuitive problem identification. B) illogical thinking. C) an assumption to guide practice. D) acute observation ability.

A) intuitive problem identification.

Ch. 16 According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is: A) physiological. B) family. C) safety. D) behavioral.

A) physiological.

CH 15 The nurse is aware that nursing diagnoses are: A) within the nursing scope of practice to develop and client-focused B) collaborative and depend on the medical diagnosis. C) based on assessment data and the primary care provider's input. D) dictated by the medical diagnoses and change day by day.

A) within the nursing scope of practice to develop and client-focused

ch14 Which client situation most likely warrants a time-lapse nursing assessment? A)An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit. B) The nurse has responded to the call light of a hospital client who is reporting shortness of breath and chest pain. C) A client is being admitted to a general medicine unit after spending several days in the intensive care unit. D) A nurse is auscultating the lungs and measuring the oxygen saturation of a client who has pulmonary edema.

A)An older adult resident of an extended-care facility is being assessed by a nurse practitioner during the nurse's scheduled monthly visit.

ch 14 For a hospital to meet criteria regarding nursing care established by The Joint Commission, the nurse must conduct which type of assessment? A)Initial B)Focused C)Physical D) Psychosocial

A)Initial

ch 14 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? A)Supplement the client's information by speaking with family or friends. B)Limit the assessment to objective data. C) Obtain the client's records from admissions to other institutions. D) Perform the assessment in several short episodes rather than at one sitting.

A)Supplement the client's information by speaking with family or friends.

ch14 When is the best time for a nurse to take a client's health history? A) After the client is settled and feels ready B) As soon as possible after a client presents for care C) WIthin 24 hours of admission D)Anytime before the client is discharged

B) As soon as possible after a client presents for care

CH 16 Which client outcome requires modification? A) Client will correctly self-administer subcutaneous insulin before discharge. B) By the end of instruction, client will know how to perform dressing changes. C) Client will demonstrate safe transfers from bed to chair within 24 hours. D) Within 2 days, client will describe two responses to firing of the internal defibrillator.

B) By the end of instruction, client will know how to perform dressing changes

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? A) Terminate the plan of care. B) Continue the plan of care. C) Promptly modify the plan of care. D) Suggest increasing the pain medication.

B) Continue the plan of care.

ch 13 Which step of the nursing process involves reporting or analysis of data to identify and define health problems? A) Assessment B) Diagnosis C) Planning D) Implementation

B) Diagnosis

CH 15 A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem? A) Disturbed Body Image related to breast cancer B) Disturbed Body Image related to loss of hair C) Disturbed Body Image as evidenced by client's refusal to look at self D)Disturbed Body Image as evidenced by client's negative comments

B) Disturbed Body Image related to loss of hair The client has a problem with body image because of the loss of hair. The evidence would be the client's statement. The etiology cannot be a medical diagnosis, so the etiology of breast cancer would be incorrect. The other two statements do not contain an etiology. Nursing diagnoses must identify an etiology to direct the client's care.

ch 20 A group of nurses are participating in being the first group of staff to use a new electronic pain assessment tool. The group is discussing whether or not the system is easy to use. During the discussion, the group mentions that "the shortcuts provided are really helpful and save valuable time." The informatics nurse specialist interprets this statement as reflecting which concept? A) Forgiveness B) Efficient interactions C) Naturalness D) Effective use of language

B) Efficient interactions

CH 15 When developing nursing diagnoses, the nurse should focus on which area? A) Actions to be initiated for treatment B) Human responses to actual or potential health problems C) Pathophysiological responses occurring in body systems D) Problem validation through physician collaboration

B) Human responses to actual or potential health problems

ch 16 Which action should the nurse perform during the planning phase of the nursing process? A) Assess the client's overall health. B) Identify measurable goals or outcomes. C) Analyze the client's response to medicines. D) Identify the client's health-related problems.

B) Identify measurable goals or outcomes.

ch 13 A client is admitted to the hospital with an abscess on the leg that will not heal after multiple treatment options as an outpatient. The nurse knows from past experiences that the appearance of this type of wound in clients heavily suggests a resistant bacterial infection and the need for contact isolation and intravenous antibiotics. The nurse begins to prepare for this admission. What type of problem solving does this exhibit? A) Experiential B) Intuitive C) Scientific D) Trial-and-error

B) Intuitive

CH 16 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) Nursing diagnosis B) Outcome C)Intervention D)Evaluation

B) Outcome

A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement? A) Adjust expected outcome to have client ambulate a shorter distance. B) Return the client to bed and provide pain relief measures. C) Ask the client to describe a personal walking goal. D) Review evidence-based interventions for the client's pain.

B) Return the client to bed and provide pain relief measures.

CH 15 Which error has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity as evidenced by an open area with a 1-inch diameter on the right buttocks surrounded by a 1-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected. A) Wrote the diagnosis in terms of a need rather than a client response B) Reversed the health problem and the etiology C) Omitted the defining characteristics of the client health problem D) Identified environmental factors rather than client factors as the problem

B) Reversed the health problem and the etiology

ch 14 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? A) Chart the data. B) Validate the data. C) Ignore the client's answer. E) Ignore the client's nonverbal behavior.

B) Validate the data.

ch 19 Besides being an instrument of continuous client care, the client's health care record also serves as a(an): A) assessment tool. B) legal document. C) Kardex. D) incident report.

B) legal document.

ch 13 A client newly diagnosed with diabetes has been sent home after in-depth education regarding the diabetes management plan. Because the client is newly diagnosed, the nurse included in the plan of care a risk for unstable glucose. What is the most appropriate short-term outcome for this nursing diagnosis in the client? The client will: A) log all meals in a diary for the next 6 weeks. B) maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). C) maintain a normal HgbA1C. D) not exhibit signs and symptoms of hypoglycemia/hyperglycemia.

B) maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L).

ch14 During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should: A) clarify the client's health status. B) review as much information as possible. C) identify existing and potential health problems. D) develop the nursing plan of care.

B) review as much information as possible.

ch 14 While performing an assessment, the nurse recognizes that the nurse's own personal biases may be interfering with the collection of data. What step should the nurse take to ensure that the information is factual and accurate? A) Verify the information with one or two family members without informing the client. B)Consult with another nurse for that colleague's description of the assessment or observations. C) Inform the client of these potential biases and obtain the client's opinion. D) Document on the client's chart that the assessment data may be biased.

B)Consult with another nurse for that colleague's description of the assessment or observations.

ch 19 A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate? A) "Be sure to write down specific information for your clinical paperwork." B) "You can get an electronic printout of client lab data to take with you." C) "Clipboards with client data should not leave the unit." D) "Be sure to put the client's name and room number on all paperwork."

C) "Clipboards with client data should not leave the unit."

ch 20 An informatics nurse specialist is conducting an in-service program for a group of staff nurses about this specialty. One of the nurses asks, "What exactly is nursing informatics?" Which response by the informatics nurse specialist would be most appropriate? A) "It involves working primarily with computers and programming codes." B) "It refers to the use of the electronic health record." C) "It combines nursing science with information management and analytical sciences." D) "It is a specialty that deals with online client educational programs."

C) "It combines nursing science with information management and analytical sciences."

ch14 Which is the purpose of a focused assessment? A) Provides breadth for future comparisons B) Suggests possible problems C) Adds depth to existing information D) Gives a comprehensive volume of data

C) Adds depth to existing information

ch14 Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training? A) Validation is an important part of assessment. B) Validation helps to keep data as free from error as possible. C) All data collected need to be validated. D) Validation is the act of confirming or verifying.

C) All data collected need to be validated.

ch 14 Which action would the nurse perform in the assessment phase of the nursing process? A) Developing a plan to manage the client's health problems B) Coming up with a nursing diagnosis based on a potential health risk C) Asking the client whether the client has cultural preferences D) Determining whether the client's goals for wellness have been met

C) Asking the client whether the client has cultural preferences

ch 17 The home health nurse caring for a client with limited eyesight notes that the client's route to the bathroom is cluttered. What is the most effective way for the nurse to ensure the client's long-term safety? A) Remove all the cluttered objects from the pathway to the client's bathroom. B) Instruct the client about the need to keep the walkway to the bathroom clear. C) Assist the client to identify strategies to promote safety in the home. D) Assign a home health aide to perform housekeeping duties.

C) Assist the client to identify strategies to promote safety in the home.

ch14 Nurses understand the problem that clients have when they are repeatedly asked the same questions. To best avoid this problem, which intervention should nurses perform when beginning to collect assessment data? A) Organize all questions into categories. B)Make the questions short. C) Carefully review the client's record. D)Tell the client the questions will be quick.

C) Carefully review the client's record.

ch 18 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? A)Report the nurse applying the restraints to the supervisor. B) File an incident report and have the second nurse sign it. C) Confront the nurse and explain how this could be dangerous for the client. D) Contact the physician for an order for the restraints.

C) Confront the nurse and explain how this could be dangerous for the client.

Which part of the client record should the nurse review to find recommendations made by a gastrointestinal specialist? A) Medical history B)Progress notes C) Consultation D) Laboratory reports

C) Consultation

Recording prioritized outcomes in the plan of care ensures which benefit? A) The client will reach the goals of the care plan. B) The nurse knows what the client wants. C) Continuity of care can be provided to the client. D) Each nurse can select which priorities to accomplish.

C) Continuity of care can be provided to the client.

ch 17 A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention? A) Surveillance B) Supportive C) Coordinating D) Technical

C) Coordinating

ch 17 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? A) Providing medication for agitation B) Repositioning to prevent pressure injuries C) Ensuring that the endotracheal tube is secure D) Changing the dressing to prevent infection

C) Ensuring that the endotracheal tube is secure

A nurse is interviewing a hospitalized client. Which nurse-client positioning facilitates an easy exchange of information? A) If the client is in bed, the nurse stands at the foot of the bed. B) If both the nurse and client are seated, their chairs are at right angles to each other, 30 cm apart. C) If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed. D) If the client is in bed, the nurse stands at the side of the bed.

C) If the client is in bed, the nurse sits in a chair placed at a 45-degree angle to the bed.

ch 15 Which is the best example of a nursing diagnosis? A) Gastroesophageal Reflux related to low stomach pH as evidenced by foul breath and burning sensation in throat. B) Ineffective Airway Clearance as evidenced by client not speaking. C) Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast. D) Cellulitis related to infection as evidenced by warm, reddened skin.

C) Ineffective Breastfeeding related to latching as evidenced by nonsustained suckling at the breast.

ch 17 A nurse is administering metformin to a client who has a new onset of diabetes mellitus type 2. Which step should the nurse consider a priority on the nursing care plan? A) Restrict intake of foods and fluids. B) Monitor for noncompliance. C) Monitor for lactic acidosis D) Administer B12 injections

C) Monitor for lactic acidosis In this scenario, the nurse is administering a medication. Because an action is being carried out, this is the implementation step of the nursing process. Following the administration of medication, the nurse should monitor the client for lactic acidosis as well as side effects of the medication. Restricting the client's food and fluids while the client is on metformin is only suggested when the client is preparing for a procedure requiring the client to be NPO. B12 injections may be indicated in the future as treatment has been established. Likewise, it is too early in the treatment plan to monitor for noncompliance.

CH 16 Which phase of the nursing process most involves establishing priorities? A) Assessment B) Diagnosis C) Outcome identification and planning D) Implementation

C) Outcome identification and planning

ch 13 The registered nurse (RN) is receiving a shift report from another RN about a client admitted for dehydration. In the report, the departing RN indicates that the client has been prescribed intravenous fluids and an antibiotic. The oncoming RN asks why the antibiotic has been prescribed. This is an example of which consideration involved in the process of critical thinking? A) Helpful resources B) Potential problems C) Purpose of thinking D) Problem solving

C) Purpose of thinking

ch15 Which action is a priority role of the nurse when caring for a client with collaborative problems? A) Assessing the client's understanding of risk factors B) Resolving health issues through independent nursing measures C) Reporting trends that suggest the development of complications D) Managing an emerging problem with the help of another registered nurse

C) Reporting trends that suggest the development of complications For a client with collaborative problems, the nurse should report trends that suggest the development of complications to bring to notice the need for collaborative intervention for the client. Collaborative problems are physiologic complications that require both nurse- and physician-prescribed interventions. Actions that exclude members of other disciplines are not characteristic of collaborative problem management. The development of complications is a priority over assessment of the client's knowledge of risk factors, even though the nurse must assess these.

ch 20 A nurse has a two-way video communication with the specialist involved in the care of a client in a long-term care facility. This is an example of what nursing informatics technology? A) Client engagement technology B) Data aggregation technology C) Telemedicine and mobile technology D) Population health management technology

C) Telemedicine and mobile technology

ch 13 The nurse is preparing to document the nursing diagnoses for a client. What is the most appropriate outcome for the nursing diagnosis of impaired gas exchange? A) The client will have clear breath sounds. B) The client will have decreased work of breathing. C) The client will maintain a pulse oximeter reading of greater than 94% (0.94 L). D) The client will maintain a respiratory rate between 12 and 20 breaths per minute.

C) The client will maintain a pulse oximeter reading of greater than 94% (0.94 L).

ch 18 The health care team has convened to discuss the care of an end-of-life client who is not able to achieve an acceptable level of comfort. The physician asks for the nurse's perspective of the situation. Which standard for establishing and sustaining healthy work environments does this action represent? A) Skilled communication B) Effective decision making C) True collaboration D) Appropriate staffing

C) True collaboration

ch 19 A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? A) Notifying the nursing team of the client's condition B) Documenting client data on the flow sheet C) Keeping an accurate medication record D) Accurately documenting client care on the client record

D) Accurately documenting client care on the client record

For a client with a self-care deficit, the long-term goal is that the client will be able to dress oneself by the end of the 6-week therapy. For best results, when should the nurse evaluate the client's progress toward this goal? A) When the client is discharged B) At the end of the 6-week therapy C) Only when the client shows some progress D) As soon as possible

D) As soon as possible

ch13 A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process? A)Planning B)Implementation C) Diagnosis D) Assessment

D) Assessment

ch 19 Which charting format permits documentation on any significant topic, not just client problems? A) CBE B) SOAP C) PIE D) FOCUS

D) FOCUS

ch 13 The nurse administers pain medication to a postoperative client. In which phase of the nursing process is this occurring? A) Assessment B) Nursing diagnosis C) Planning D) Implementation

D) Implementation

ch 14 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? A) Recheck the client's pulse in 2 hours. B) Recheck the client's pulse at the next scheduled assessment time and document the findings on the chart. C) Document the findings on the chart and recheck in 1 hour. D) Notify the physician of the change and document the finding. E)Notify the physician after the next scheduled assessment time if the pulse is unchanged.

D) Notify the physician of the change and document the finding.

CH 16 What are specific measurable and realistic statements of goal attainment? A) Nursing diagnoses B) Nursing interventions C) Evaluations D) Outcomes

D) Outcomes

ch 18 The nursing supervisor is presenting the staff nurses with yearly performance evaluations. What type of evaluation is the supervisor presenting to the staff? A) Outcome B) Technical C) Structural D) Process E) Goal

D) Process Process evaluation focuses on the nurse's performance and whether the nursing care provided was appropriate and competent during the period of the evaluation. Outcome evaluation and goal evaluation are used by the nurse as part of the nursing process to evaluate the client's response to interventions and success in meeting established goals. A technical evaluation focuses specifically on a nurse's ability to perform certain technical nursing skills. A structural evaluation or audit focuses on the environment in which care is provided.

ch 14 The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next? A) Cover the infant. B) Ask the parent whether the child has been exposed to cold temperatures. C) Assess the skin for signs of cyanosis. D) Recheck the temperature, paying close attention to technique.

D) Recheck the temperature, paying close attention to technique.

ch 18 Which action should the nurse perform in the evaluation phase? A) Carry out treatment procedures. B) Set priorities for care. C) Record interventions. D) Revise the plan of care.

D) Revise the plan of care. The nurse should revise the plan of care during the evaluation phase. It provides the feedback mechanism that starts the entire chain of events again. Setting priorities is part of the planning phase. Carrying out treatment procedures and recording interventions are activities in the implementation phase of the nursing process.

ch 16 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 oxygen at 4 L/min per nasal cannula. C) Administer a 1000-mL soap suds enema. D) Teach the client how to splint an abdominal incision when coughing and deep breathing.

D) Teach the client how to splint an abdominal incision when coughing and deep breathing.

ch 14 The nurse is summarizing the key points of the interview. This nursing activity occurs during which phase? A) Preparatory phase B) Introductory phase C) Working phase D) Termination phase

D) Termination phase

ch 18 Which nursing action reflects evaluation? A) The nurse identifies that the client does not tolerate activity. B) The nurse sets a tolerable pain rating with the client. C) The nurse auscultates the client's lungs and abdomen. D) The nurse assesses urine output following administration of a diuretic.

D) The nurse assesses urine output following administration of a diuretic.

ch 14 A client is a poor historian of the client's past medical history. Whom should the nurse consult about the client's past history? A) Physician B) Old chart C) Social worker D)Family

D)Family

ch 20 An informatics nurse specialist is collecting data from the clinical information system about the demographics of individuals diagnosed with heart failure admitted to the facility over the past five years. The nurse specialist is preparing a presentation to the facility's executive board. To promote understanding of this complex information, the nurse specialist prepares the data results using a pie chart and a bar graph. The nurse specialist is using which area of analytics? A) Data visualization B) Predictive analytics C) Big Data D) Data mining

Data visualization

ch 15 A client undergoing chemotherapy for breast cancer has lost all hair. The client states, "I cannot stand to see myself without hair. I am disgusting." What would be the most appropriate nursing diagnosis for the nurse to use to address this client's problem? A) Disturbed Body Image related to breast cancer B) Disturbed Body Image related to loss of hair C) Disturbed Body Image as evidenced by client's refusal to look at self D) Disturbed Body Image as evidenced by client's negative comments

Disturbed Body Image related to loss of hair

CH 15 Which are benefits of using nursing diagnoses when creating the nursing care plan? Select all that apply. -Improves communication between nurses caring for the client -Standardizes the care provided by members of other health disciplines -Allows nurses to practice without accountability to other health disciplines -Directs areas of nursing research -Encourages the client's participation in care

Improves communication between nurses caring for the client Directs areas of nursing research Encourages the client's participation in care

ch 20 A client comes to see the cardiologist for a routine follow-up visit. At the visit, the nurse reviews the client's electronic health record. The nurse is able to access a report from the client's last visit to the primary care provider last month and the report from an emergency department visit two weeks ago for reports of shortness of breath. The record also lists two changes in the client's medication based on the emergency department visit. The nurse's ability to access this information reflects which concept? A) Usability B) Interoperability C) Optimization D) Security

Interoperability

ch14 The nurse must be familiar with the client record in order to provide care effectively. Which parts of the client record include only the findings of physicians? Select all that apply. -Medical history -Physical exam -Care plan -Progress notes -Laboratory values

Medical history Physical exam Progress notes

ch14 Which statements accurately describe the unique focus of nursing assessments? Select all that apply. -Nursing assessments duplicate medical assessments. -Nursing assessments target data pointing to pathologic conditions. -Nursing assessments focus on the client's responses to health problems. -The findings from a nursing assessment may contribute to the identification of a medical diagnosis. -The focus of a nursing assessment is on actual, not potential, health problems. -An initial assessment establishes a complete database for problem solving and care planning.

Nursing assessments focus on the client's responses to health problems. The findings from a nursing assessment may contribute to the identification of a medical diagnosis. An initial assessment establishes a complete database for problem solving and care planning.

acronym used to write an appropriate patient outcome statement

S- specific M- measurable A- attainable R- realistic T- time bound

ch 18 Which are purposes of the evaluation phase of the nursing process? Select all that apply. -To determine the client's responses to nursing interventions -To appraise the extent to which client goals were attained -To determine the involvement and collaboration of the client, family members, nurses, and health care team members in health care decisions -To ensure that the plan of care was followed as it was originally prepared -To collect subjective and objective data to make judgments about nursing care delivered

To determine the client's responses to nursing interventions To appraise the extent to which client goals were attained To determine the involvement and collaboration of the client, family members, nurses, and health care team members in health care decisions To collect subjective and objective data to make judgments about nursing care delivered

ch 20 An informatics nurse specialist is conducting an in-service education program for a group of staff nurses. The topic is ensuring electronic client data is secure and private. The specialist determines that the teaching was successful when the group identifies which aspect as essential to ensuring the security of electronic data when using clinical systems? A) Use of strong passwords B) Thorough knowledge of interoperability C) Intuitive system design D) Testing

Use of strong passwords

introductory phase

introduction takes place; nurse outlines expectations for interview

Preparatory phase

nurse prepares setting for interview and reviews any available info about client

termination phase

nurse summarizes key points of the interview

working phase

the nurse collects subjective data