fundamentals of nursing prep u final review

Which action should the nurse take during the evaluation phase of the nursing process?

Document reassessment of pain after medication administration. Explanation: The evaluation phase includes documenting a reassessment of pain following an intervention such as the administration of pain medication. Providing a client with an appointment and discontinuing an indwelling urinary catheter are interventions. Having a client give input into a plan of care is part of the planning process.

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?

Encourage the client to provide as much self-care as possible. Explanation: The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered.

Which action by the nurse is an example of peer review?

The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation. Peer review involves the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization for the purpose of professional performance improvement. The nurse preceptor providing feedback to the new graduate nurse after 6 weeks of orientation is an example of peer review. The nurse manager and the UAP are not on the same level in the organization as the nurse. Consulting policies and procedures is not peer review.

A client who has been in a vegetative state for years is scheduled for an elective surgery. The nurse is questioning whether the procedure is necessary. What is the nurse's appropriate first action?

The nurse should address the concern with the surgeon. Explanation: The nurse should first address the concern with the surgeon who has scheduled the procedure. If the nurse still has concerns after the discussion with the surgeon, the other choices are possible courses of action.

A nurse is conducting an interview with a client who reports abdominal distress. What is an appropriate interview question for this client?

"What is your problem as you see it?" Explanation: Asking the question, "What is your problem as you see it?" is an exploratory and open-ended question that encourages the client to provide the client's own feelings and interpretation of the current problem. Asking the client whether he has eaten something that could have been spoiled, whether he may have appendicitis, and when the last bowel movement occurred are leading questions that block the client's own feelings and response. Reference:

Health promotion nursing diagnoses consist of how many parts?

1 Explanation: A health promotion nursing diagnosis consists of a one-part statement that includes the diagnostic label. An actual nursing diagnosis consists of three parts; risk and possible nursing diagnoses consist of two-part statements.

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 Explanation: For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse. Delegation of taking vital signs would be appropriate for all of the other client's described.

A nurse is applying the nursing process and is in the diagnosis phase. With which activities would the nurse be involved? Select all that apply.

Analyzing data Identifying patterns Identifying indicators of potential dysfunction Explanation: During the diagnosis phase, the nurse analyzes collected data; identifies client strengths; identifies the client's normal functional level and indicators of actual or potential dysfunction; identifies patterns; validates the diagnosis; and formulates a diagnostic statement in relation to this synthesis. Collecting and organizing data are assessment activities.

The nurse formulates for a client the nursing diagnosis of: Impaired Physical Mobility related to postoperative pain as evidenced by difficulty ambulating. Which component of this nursing diagnosis is the descriptor?

Impaired Explanation: Descriptors are words used to give additional meaning to a nursing diagnosis. They describe the change in condition, state of the client, or some qualification of the specific nursing diagnosis. In this example, the word "impaired" is a descriptor. Physical mobility is the diagnostic label. Postoperative pain is the related factor or etiology contributing to the problem. Difficulty ambulating is the defining characteristic, or the cue that supports the existence of the problem

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task?

Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. Explanation: Instruct the UAP to repeat the nurse's instructions to be sure the nurse has communicated them clearly. The UAP must be clear on the difference between nursing tasks and the nursing process, as the nursing process structures care delivered by the registered nurse. Although it is important for the UAP to follow procedure manuals, it is important that the registered nurse is clear on the UAP's understanding of the steps through direct observation or discussions. It is not correct to ask another UAP to observe and assist the UAP in performing the task.

Which is the primary benefit of outcome identification?

It promotes the client being an active participant in care. Explanation: Outcome identification serves the purpose of promoting client participation. Evaluation takes place after the nurse has identified outcomes and performed interventions and thus is not the primary benefit of outcome identification. Nursing diagnosis occurs before outcome identification and thus is not its primary benefit.

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "The client will know how to self-administer prescribed bronchodilators using a nebulizer by 09/09/2020." Why is this outcome inadequate?

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

When establishing client outcomes with the client, what is the qualifier in the outcome?

The outcome parameter Explanation: The qualifier is a description of the parameter for achieving the outcome. Short-term and long-term goals and the problem statement are distinct from establishing client outcomes.

The nurse has established client outcomes and outcome criteria. What should the nurse do next?

Write a client plan of care Explanation: The planning phase involves writing a client's plan of care based on the outcomes identified during outcome identification. Goals, objectives, and outcomes are terms often used interchangeably, because they are statements of expectations. As such, they would be established during outcome identification, after priorities have been identified.

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome? You Selected:

At the completion of each meal Explanation: The nurse should collect data at the completion of each meal to ensure the accuracy of the data and to monitor the client's progress toward meeting the goal so that the nurse can make changes to the plan when the client fails to make sufficient progress or celebrate with the client when the client demonstrates success. Although the final evaluation of goal attainment must occur on or shortly after 3/2, data collection must begin far earlier than that. It would not be appropriate for the client to direct when data collection should occur.

Which phase of the nursing process most involves establishing priorities?

Outcome identification and planning Explanation: During outcome identification and planning, the nurse establishes priorities as well as client goals and outcomes. During this phase, the nurse also plans nursing interventions and writes the plan of care. Assessment involves data collection; diagnosis involves identifying client problems. Implementation involves putting the plan of care into action.

A client has been diagnosed with pneumonia and is experiencing chest pain when taking a deep breath. What are the priority nursing diagnoses? Select all that apply

Acute Pain Ineffective Airway Clearance Explanation: While all are important diagnoses, respiratory function and pain are priority. This client could be at risk of developing an infection or experiencing increased anxiety if worsening breathing difficulties are experienced. Being able to swallow and eat would be a late developing complication if earlier interventions were unsuccessful

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply.

Assisting the client with personal hygiene needs and ambulation Transporting the infant to the mother's room according to hospital policy Explanation: It is essential when delegating duties that the registered nurse (RN) is aware the nurse's role and what duties can be delegated. The nurse also must be aware of the training and the competence of the UAP. The nurse could appropriately delegate assisting with personal hygiene needs, ambulation, and transporting the infant to the mother's room according to hospital policy. Assessment is the role of the RN and cannot be delegated. Teaching, including breastfeeding education and discharge instructions, is also the role of the RN and cannot be delegated.

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 Explanation: The NIC provides a form of standardized language for use by nurses. Additionally, the NIC helps to expand the knowledge of similarities and differences across nursing diagnoses and explore nursing care information systems. Use of this model aids in determining the costs of services that nurses provide and demonstrating the impact of nurses on overall health care costs. Use of acuity and workload management tools, not the NIC, aids in justifying staffing levels based on productivity. State nurse practice acts, not the NIC, help determine which nursing actions the nurse may delegate.

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 Explanation: The nurse is supervising the client's skill performance with regard to assuming responsibility for the self-management of his diet. This may require reinforcement of education, support, or coordination interventions - but is primarily a supervisory intervention.

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?

Collaborate with other disciplines to determine the best way to meet the client's medication requirements. Explanation: In order to meet the client's needs, it is most important to involve other disciplines in the client's care to utilize all available resources. Reinforcing the importance of the medication does not solve the financial problem. It may be necessary for the physician to prescribe a less expensive medication, but other options should be considered to address the holistic needs of the client. Some pharmaceutical companies have programs to help with medication expenses, but the client will need information in order to apply for the programs.

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders. Explanation: If the nurse's interventions have been ineffective, the physician must be notified of the client's deteriorating status. The physician can direct other medical interventions. Documenting the interventions does not take priority over the client's physiologic needs. Allowing another 30 minutes to elapse before taking action will only cause further deterioration in the client's status. The nurse should know the client's code status when taking over the client's care.

The nurse determines that the client is not meeting some of the expected outcomes in the plan of care. What are the next steps in the process? Select all that apply.

Reevaluate each step of the nursing process. Identify contributing factors. Collect additional data. Add or alter nursing diagnoses. Explanation: There would not be a need to delete all of the expected outcomes. The ones that the client is not making progress toward meeting may need to be altered, but it would not be necessary to delete them all. The other choices would be appropriate in modifying the plan of care.

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful?

The client is free of falls. Explanation: Interventions for risk diagnoses are directed at prevention. The most appropriate way to evaluate the success of the interventions is to determine if the risk was prevented. The best evaluation criteria would be if the client remained free of falls. The client calling for assistance might prevent a fall, but does not signify that a fall will not occur. Teaching clients safety precautions and having the client verbalize risk for injuries is important but does not necessarily mean that an injury is prevented.

Which examples are essential components for delegating nursing care to an unlicensed assistive personnel (UAP)? Select all that apply.

The UAP has sufficient knowledge and skill for completing the task. The nurse has clearly communicated instructions to the UAP. The UAP can verbalize what information to report to the nurse. Explanation: Essential components of effective delegation include delegating the task to to a person with sufficient knowledge and skill for completing the task; communication of clear and specific instructions by the nurse to the UAP; and validation of understanding by the UAP regarding information to be reported to the nurse. Planning and evaluating remain the responsibility of the nurse and are not delegated to UAP.

After sustaining a wrist fracture in a recent fall, a client is suspected of having osteoporosis. Which data best demonstrates the nursing focus of assessment?

The client claims mobility and independence have declined in recent years. Explanation: Nursing assessment focuses primarily on clients' responses to health problems, such as the effect of illness on activities of daily living (ADLs), mobility, and independence. The client's blood work, diagnostic results, and skeletal structure are relevant contributors to these considerations, but they are more indicative of a medical assessment framework.

The nurse is responsible for recognizing significant data when developing nursing diagnoses. Which significant data would indicate a health problem may exist? Select all that apply.

The client has a blood pressure reading of 150/90 mm Hg. During assessment, the client is sweating and short of breath. The client only answers yes or no questions. Explanation: The subjective and objective data that would be considered significant in this scenario are elevated blood pressure, sweating and shortness of breath, and client responses. Individually, each of these data may not be considered abnormal. However, as a cluster they may indicate that a problem exists. The other findings are within normal range and do not signify a problem at this time.

Which actions are examples of nursing actions listed in the ANA's Nursing: Scope and Standards of Practice for Standard 5: Implementation? Select all that apply.

The nurse documents implementation and any modifications, including changes or omissions, of the identified plan. The nurse utilizes community resources and systems to implement the plan. The nurse utilizes evidence-based interventions and treatments specific to the diagnosis or problem. Explanation: ANA's Nursing: Scope and Standards of Practice for Standard 5 refers to the implementation phase of the nursing process, including documentation of implementation, use of community resources for implementation, and use of evidenced-based interventions. Incorporation of new knowledge refers to Standard 6, Evaluation. Documentation of the plan of care and development of expected outcomes is found in Standards 3 and 4, Outcome Identification and Planning.

Which nursing intervention is most likely to be allowed within the parameters of a protocol or standing order?

Administering a glycerin suppository to a constipated client who has not responded to oral stool softeners Explanation: Standing orders and protocols often surround the management of bowel elimination. Modification of a client's IV fluid or administration of a new antihypertensive are client-specific interventions that are physician initiated. The care team cannot independently change a client's advance directive.

A client has been discharged from an acute care facility with a referral for a home health nurse to make an assessment. What is the priority action by the home health nurse on the initial home visit?

Establish the client's database. Explanation: An initial assessment is performed when the client enters a health care facility, receives care from a home health agency, or is seen for the first time in an outpatient clinic. This serves as the basis of the nursing process for that client within the new setting for the course of that health issue. The nurse should establish the client's database before caring for the client's pain, evaluating care previously received, or receiving a report from the nursing staff

The nurse is reassessing a client with leukemia who has received several packed red blood cell transfusions over the past week. Which question should the nurse ask the client to evaluate the treatment?

Have you had any fevers? Explanation: The administration of red blood cells is intended to correct an anemic condition in a client with leukemia. Leukemia destroys the bone marrow's ability to produce healthy white blood cells, red blood cells, and platelets. Headaches occur in patients with anemia as a result of decreased oxygenation, which causes arterial swelling. Joint or bone pain occurs as a result of the expansion of bone marrow from the accumulation of white blood cells. Bruising is a symptom of thrombocytopenia which occurs as a result of a decreased platelet production

A nurse is evaluating the plan of care for a client in the clinic. Which actions should the nurse perform, as classic elements of evaluation? Select all that apply.

Identifying evaluative criteria and standards Collecting data to determine whether criteria and standards are being met Interpreting and summarizing findings Terminating, continuing, or modifying the plan of care Explanation: The nurse must document findings as they relate to the plan of care but should also include the nurse's judgement as to whether the outcomes are being met. All of the other choices are criteria for evaluation.

Other than the client, what sources of client information should the nurse consider when assessing a client? Select all that apply.

The client's support people The client's health record Family members accompanying the client Other health care professionals Explanation: When assessing, the primary source of client information is the client. Other sources the nurse should consider include the client's support people, the client record, family members accomapanying the client, and other health care professionals. It would not be appropriate to use other clients as a source, because this would violate confidentiality. Reference:

A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective?

Client will use chin tuck and double swallow for each bite. Explanation: Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these actions will improve oral intake by the client with dysphagia, the most effective is a chin tuck and double swallow. These actions reduce the risk of aspiration and aid the movement of food down the esophagus. Reference:

While performing the nursing history, the nurse notes that the client reports having very little pain but is occasionally grimacing and rubbing one shoulder throughout the interview. The nurse acknowledges this behavior, questions the client, and then proceeds with other phases of the interview. This action takes place during which phase of the nursing interview?

Maintenance Explanation: Watching the client to determine whether nonverbal cues match the verbal communication typically occurs during the maintenance, or working, phase of the interview. Initial observations are noted during the introductory phase, when the nurse introduces oneself to the client, but they are further addressed in the maintenance phase. The preparatory phase is the time before the nurse actually meets with the client, during which the nurse gathers as much information about the client's health status as possible and plans for the interview and assessment. The concluding phase is when the nurse signals to the client that the interview is coming to a close and asks whether the client has any remaining questions. Reference:

A nurse identifies an area where client care has been compromised. What steps should the nurse take to improve performance? Select all that apply.

Plan a strategy using indicators. Assess the change. Discover a problem. Implement a change. Explanation: Clients are not always aware of problems on a clinical unit. For example, if blankets are not being supplied to the unit per facility policy the client may not be aware because the nurse went and got one from another unit; however, there is a problem that should be addressed. The other choices are all part of the process to improve performance.

Which tasks can the nurse appropriately delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

Record the client's intake and output. Assist the client to the bedside commode. Explanation: It is crucial for the nurse to be aware of the legalities of delegation to UAPs. Appropriate delegation to a UAP would include recording intake and output and assisting the client to the bedside commode. Assessment of the client's educational needs and the risk for pressure injuries fall only under the nurse's scope of practice. Administering oral medications is not appropriate for UAPs.

A client had a cholecystectomy 2 hours previously and is waking up from anesthesia. The client asks, "how long it will be before I can go home?" The nurse responds that most clients are discharged within 2 days. The nurse's answer is most likely based on which piece of information?

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

Which scenario represents a nurse demonstrating the critical thinking process?

assessing whether physician help is needed Explanation: Critical thinking involves consistency, relevancy, and logical thinking. It enables the nurse to make decisions. Therefore, assessing whether physician help is needed is an example of the critical thinking process. The other actions support other nursing soft skills.

The nurse determines that a client has not met the goal of consuming at least 80% of each meal served by a designated date. Which would be appropriate responses by the nurse to the client regarding this lack of goal attainment? Select all that apply.

"Do you think it is possible that you will be able to eat 80% of the food served here?" "What kinds of things have we been doing to increase your appetite?" "Do you think you could meet the goal if we check on it in one week or so?" Explanation: The nurse should review the goal to determine whether it is realistic, review the actions taken to move the client toward goal attainment, and consider changing the time line for evaluation. There is no indication that discarding the goal is necessary. By asking whether the client is trying as much as possible to eat 80% of each meal, the nurse infers that the failure to meet the goal is the client's fault. This blame-placing should be avoided.

The home care nurse is preparing to perform a nursing history on a newly assigned adult client with a venous stasis ulcer. Which statement by the nurse is most accurate?

"I would like to schedule a time for me to perform a nursing history. It will take around 30 to 60 minutes." Explanation: Nurses are responsible for completing nursing histories, and it usually takes approximately 30 to 60 minutes to obtain data such as history of present illness, past medical history, support network, and other pertinent data. The physical assessment is performed separately. Family members can offer valuable information, as long as the client gives permission for them to remain present during the history taking.

Before implementing any intervention, which questions should the nurse ask oneself? Select all that apply.

"Is the client prepared for what needs to be done?" "Do I have all the necessary supplies and equipment needed?" "Do I have the skills to perform the intervention?" "Can I do the intervention alone or do I need help?" "Have I obtained permission from the physician to perform this intervention?" Explanation: In today's hectic health care environments, successful implementation of the care plan requires a high degree of organization and efficiency. This includes the following: making sure that the client is physically and psychologically prepared for what you are going to do; having the necessary equipment and supplies readily available; ensuring that interventions are attempted by the right person or by a sufficient number of people; and being prepared with the skill and knowledge necessary to deal with the situation if something goes wrong. The nurse does not need to obtain permission from the physician to perform any intervention, although if it is a physician-initiated intervention, the nurse should have a physician's order before carrying it out.

A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient facility. The client has not brought a log of daily glucose checks and tells the nurse, "I haven't been doing them regularly." What is the nurse's most therapeutic statement to the client?

"It seems like you are having difficulty with your care regimen." Explanation: The nurse's open-ended statement acknowledging that the client is having difficulty with the care regimen encourages the client to discuss what has occurred that has caused the client to not manage the diabetes as was previously done. The statement reminding the client that health care is important will discourage the client to freely discuss any problems. A home health nurse or instructions given to the family may be indicated, but not until the client has verbalized the reasons why the care regimen has not been followed.

An 87-year-old client has been admitted to the hospital several times in the past few months for exacerbations of chronic obstructive pulmonary disease and elevated blood glucose levels. Which statement by the client could help identify the most likely reason for the changes in the client's health status?

"My wife's been gone for about 7 months now." Explanation: The client's loss may be affecting how well the client is able to provide self-care. The client may be depressed and questioning the benefits of the health care regimen, or the client may have depended on the wife to help with health care and no longer has the ability to take care of himself. Assessment of the client allows the nurse to alter the plan of care to meet the client's needs. The statements concerning having a family member staying with the client, having help with the yard work, and sorting medications into an organizer all indicate factors that would improve the client's ability to provide self-care, not decrease it

The nurse is terminating an interview with a client in the behavioral health unit. Which statements by the nurse would indicate an effective termination of the interview? Select all that apply.

"We have 5 minutes left. Do you have any questions?" "What are some of your most important concerns?" "Here is my card with my phone number. Please call if you have concerns." Explanation: Some therapeutic ways to terminate an interview are to give a warning, ask the client to summarize the most importance concerns, ask "what else?", offer yourself as a resource, and explain all care routines. The nurse should not tell the client that the nurse is terminating an interview to check on someone else, as this gives the message that another client is more important. Asking a client whether the client wants to continue is not appropriate, as this implies that the information is not that important.

The nurse is interviewing a client and is focusing on avoiding comments and questions that will impede communication. Which sentence demonstrates the appropriate use of communication techniques?

"When did you first notice the rash on your leg?" Explanation: An example of appropriate communication is the statement, "When did you first notice the rash on your leg?" This is an example of a direct question that can be asked to validate information or clarify information. The other sentences demonstrate poor communication techniques. The nurse should avoid cliches, questions that require a "yes" or "no" answer, intimidating "why" and "how" questions, probing questions, and using judgmental comments.

The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which should the nurse recognize as an example of outcome evaluation?

A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery Explanation: Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. Structure evaluation focuses on the environment in which care is provided, such as the number of baccalaureate-prepared nurses employed in the facility and bed occupancy rates. Process evaluation focuses on the nature and sequence of activities carried out by nursing implementing the nursing process, such as a rate of 98% of clients admitted to the hospital who had a nursing history completed within 24 hours after admission.

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?

Assist the client to identify strategies to promote safety in the home. Explanation: The best way to address safety in the home is to discuss the issue with the client. Because the client has a visual deficit, clutter in the pathway to the bathroom may not be the only hazardous condition in the home. Helping the client identify safety strategies will help the client be more independent and will promote safety in the long run. Removing the cluttered objects would be important for the client's immediate safety, but would not help keep the client safe in the long run. Instructing the client to keep the walkway clear without identifying ways to do it would not keep the client safe. A home health aide could be part of the overall strategy to help protect the client, but the aide will not be present all the time to protect the client.

The nurse is preparing to evaluate the goals set for a newborn and mother. What physiologic goals will the nurse evaluate for effectiveness? Select all that apply.

By 4/6/20, the newborn will demonstrate 2 hours of sleep prior to breastfeeding at night. By 4/6/20, the mother will demonstrate a pain rating of 0 on a 0 to 10 scale. Before discharge, the baby with a birth weight of 7 lb, 6 oz (3.3 kg) will have reached a target weight of 8 lb (3.6 kg). Explanation: Physiologic goals meet the need of normal, healthy body functioning. An infant's sleep-wake patterns, comfort level, and weight are all examples of physiologic goals/outcomes. Decreased anxiety of the parents and demonstration of confidence in bathing their baby are affective outcomes. Listing appropriate resources is a cognitive goal.

The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. What short-term client goals help prepare the client for discharge? Select all that apply.

Client will increase nutrition, eating 75% of meals. Client will report pain is controlled at or below 3 of 10. Client will perform dressing change independently. Explanation: The focus of planning for a client who is expected to make a full recovery is promotion and restoration of health, alleviation of suffering, and prevention of illness, injury, and disease. A client recovering from surgery needs adequate pain control, sufficient nutritional intake for healing, and education in self-care if there are special needs, such as treating a wound, caring for a port, or administering medications. The oxygen saturation level is too low. The influenza vaccine should not be administered to someone with a moderate to severe acute illness. Reference:

Which is an appropriate expected outcome for a client?

Client will independently follow transplant medication schedule 1 week after surgery. Explanation: Outcomes should be specific, measurable, attainable, realistic, and timebound. Expecting a transplant recipient to follow the medication schedule after surgery is reasonable and meets all the characteristics of an outcome. The other options are not complete. Common errors to avoid when writing outcomes are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, using verbs that are not observable, and using verbs that are not measurable, such as "know" and "understand."

The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome?

Client will maintain nutritional intake without pain or diarrhea. Explanation: The best long-term client outcome is to maintain nutritional intake without pain or diarrhea. The other outcomes are smaller increments that help the client reach the ultimate goal of controlling the disease. A formal plan of care allows the nurse to individualize care for maximal achievement of outcomes, set priorities, coordinate care, promote health care communication, and evaluate client response to care. The client understanding what inflammatory bowel disease is does not indicate a measurable goal.

The nurse is preparing to interview several clients during clinic hours. What language difficulty might a nurse encounter while performing various interviews in a diverse population of clients?

Clients not being fluent in the same language as the nurse Clients having a limited education Clients fearing saying the wrong thing Explanation: In regards to language difficulty, some examples that might interfere with a interview include the following: the client not speaking the same language as the nurse; the client having a limited education; and the client fearing saying the wrong thing. If a client speaks the same language there should not be a problem. Although being anxious might cause a problem during the interview, it is not associated with a language problem.

After performing an assessment on a client, the nurse determines that the client is having difficulty with airway clearance. The nurse supports this suspicion by listing as evidence: a nonproductive cough, crackles in the lower lobes, and a pulse oximeter reading of 94%. The nurse used which process?

Clustering Explanation: Clustering related data helps the nurse look for and test impressions about patterns of human functioning. Putting like data together—for instance, objective data related to the respiratory system, such as cough, crackles, respiratory rate, and pulse oximetry—can better help the nurse identify problems and trends. To verify is to make sure or demonstrate that something is true, accurate, or justified. To infer is to deduce or conclude information from evidence and reasoning rather than from explicit statements. To clarify is to make a statement or situation less confusing and more clearly comprehensible.

A client in the last stages of pancreatic cancer tells the nurse, "I am tired of fighting. I am ready to die." What is the nurse's best action?

Collaborate with other disciplines to plan end-of-life care for the client. Explanation: The client has indicated an acceptance of the terminal condition. To respect the client's wishes, the nurse should involve other disciplines, such as hospice care, in planning for the client's needs. The client has not asked the nurse for other treatment options, so researching other options is not honoring the client's wishes. Reminding the client to think "positive thoughts" dismisses the seriousness of the client's concerns. Speaking with a spiritual adviser might be part of the collaborative care, but it would not address all the client's needs.

Which activities does the nurse engage in during the evaluation phase? Select all that apply.

Collects data to determine whether desired outcomes are met Assesses the effectiveness of planned strategies Adjusts the time frame to achieve the desired outcomes Explanation: During the evaluation stage, the nurse collects data to determine whether desired outcomes are met, assesses the effectiveness of planned strategies, and adjusts the time frame to achieve the desired outcomes. The nurse establishes desired outcomes with the client and family during the outcome identification and planning stage. The nurse initiates activities to achieve the desired outcomes during the implementation stage.

The nurse is collecting data from a client during a complete assessment. Which skill is the nurse demonstrating when documenting the assessment data?

Communication Explanation: The client data collected are of no benefit to the client unless they are appropriately communicated. Appropriate communication involves correct timing and proper documentation. Clustering data is identifying data that are relevant to a specific system. Validation of data is having a sound basis in logic or fact, or the nurse making sure the information collected is correct. Collection of data occurs during the beginning of the client assessment.

A client with congestive heart failure has dyspnea while ambulating to the bathroom. The nurse selects the nursing diagnosis of "Activity Intolerance" to address this health problem. Which etiology would be appropriate to select for this nursing diagnosis?

Compromised oxygen transport Explanation: The pathophysiology of congestive heart failure decreases the body's ability to transport oxygen through the body. There is no evidence of the client's unwillingness to ambulate. Cardiac disease is a medical diagnosis. Fluid overload is not necessarily the rationale for the activity intolerance, because it is the heart's failure to pump effectively that reduces the ability to transport oxygen to the organs.

The nurse is conducting a health history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?

Continue the health history with questions focusing on respiratory function. Explanation: First, the nurse needs to validate the data with the client, who is the primary source. The nurse can validate data with the health care provider but consulting with the client is the best option. The client must give permission for family members to participate in the health history. Ultimately, the nurse documents all assessment data, both from the history and the physical exam. It is appropriate to note inconsistencies between objective and subjective data

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?

Coordinating Explanation: Coordination involves acting as a client advocate, making referrals for follow-up care, collaborating with other health care team members, and ensuring that the client's schedule is therapeutic. This is not a surveillance or technical type of intervention. The nurse is being supportive of the client, but advocacy is more closely associated with coordinating types of interventions.

A nurse is evaluating a client to determine outcome achievement. The nurse determines that the client's outcome was partially met. When documenting the evaluative statement, the nurse records which other information?

Data that support the decision of the outcome being partially met Explanation: The two-part evaluative statement includes a decision about how well the outcome was met, along with client data or behaviors that support this decision. Client statements, reasons for not meeting the outcome, and revisions to the outcome statement are not included.

A nurse is reviewing a client's plan of care. What would the nurse determine is a problem related to the assessment phase of the nursing process?

Database does not reflect changes in the client condition. Explanation: Database input is done during the assessment phase of the plan of care. Nursing diagnoses are formed during the diagnosis phase of the nursing process. The plan of care is established during the planning phase of the nursing process. Inefficient use of nursing resources is part of the implementation phase.

A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking." What is the priority nursing diagnosis?

Deficient Diversional Activity Explanation: Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, or circulation. Safety issues, such as threats of self-harm, are also highest priority. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. In this case, the priority focus is diversional activity since the client must allow healing before walking and beginning physical therapy. While the other options are implied in the case, there is no direct evidence that they are higher priority than diversional activity.

Which is true of nursing diagnoses?

Describe the client's response to the health problem Explanation: Nursing diagnoses describe the client's response to the health condition, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions, but does not include communicating treatment requirements. A nursing diagnosis describes an actual, risk, or health promotion human response to a health problem that nurses are responsible for treating independently. A medical diagnosis conveys information about the signs and symptoms of disease processes; it provides a convenient means for communicating treatment requirements and describes a disease or pathology of specific organs or body systems.

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?

Discuss with the client the reasons for declining surgery. Explanation: The nurse needs further information before deciding what interventions are necessary, so the most appropriate action is to determine the client's reasons for refusal. Until the information is collected, the nurse cannot decide whether reviewing the risks and benefits of surgery would be effective. It is also premature to ask the client to discuss the decision with family members. It is not appropriate to notify the physician until the assessment is complete.

The nurse manager is holding a staff meeting and indicates that the unit is looking at a 3% budget cut for the coming year. The nurse manager asks the staff what they see as priorities for the unit, and solicits suggestions from the staff as to what budget areas might be reduced. Which standard for establishing and sustaining healthy work environments does this action represent?

Effective decision making Explanation: Effective decision making ensures nurses are active, valued partners in making policy, directing and evaluating clinical care, and leading organizational operations. Appropriate staffing ensures that client needs are effectively matched with nurse competencies. Micromanagement would be demonstrated by the manager not asking for opinions and proceeding with decision making without input. Meaningful recognition highlights the value each nurse brings to the work for the organization, such as certification.

The nurse is caring for a client who has been diagnosed with a sexually transmitted infection (STI). The nurse plans to address the nursing diagnosis of Risk-Prone Behavior. What assumption has the nurse made?

Having an STI means the client is sexually promiscuous. Explanation: Risk-Prone Behavior identifies habits of the client that are dangerous. Being sexually promiscuous would be a dangerous behavior. Risk-Prone Behavior does not mean that the client does not understand how to prevent repeated infection, the risks of unprotected sex, or the complications of STIs. Therefore, there is no evidence that the nurse has made any of these assumptions.

A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain?

Implement the ABC guide of pain management. Explanation: Because administering a pain medication is implementing the plan of care, the next step would be to monitor and evaluate the client's pain level. By using the ABC guide to pain mannagement in reassessing the client's pain, the nurse knows whether the current plan of care is safe and effective for the client, or if changes need to be made to meet the client's needs. Stating the use of pharmacologic and nonpharmacologic pain management modalities and ambulation and reviewing goals for comfort are all interventions to reduce pain, not methods for monitoring pain or evaluating the current plan.

The RN is orienting a new nurse who suggests a different way to perform a procedure. What is the RN's most appropriate reaction?

Listen to the new nurse's suggestion and evaluate its usefulness. Explanation: It is appropriate for health care professionals to be constantly evaluating whether the client's needs are being met in the best way. The experienced nurse should listen to the ideas of the new nurse and decide if the approach would be beneficial to the client. If the nurse's initial reaction is to quote policy and procedure, it does not allow for the exchange of ideas with the new nurse. It would not be necessary to consult with another experienced nurse or with the client's physician.

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?

Monitor for lactic acidosis Explanation: 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.

The sclerae of a 3-day-old infant have a yellowish tint, and the nurse has just received an order to initiate phototherapy. Which nursing diagnosis should the nurse use to plan care for this client?

Neonatal Jaundice Explanation: The yellow color of the sclera indicates jaundice, which is a common problem in the neonatal period. It is related to difficulties in bilirubin conjugation. "Risk for Neonatal Jaundice" is inappropriate because the client is already jaundiced. Jaundice signals liver dysfunction, not any problems with vision.

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 case manager The nurse case manager is the expert on resources available for the client's care. The nurse manager is responsible for the operation of the nursing unit. The physician is concerned with the client's medical needs. The insurance company is a possible resource, if the client has insurance coverage.

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning?

Nursing assistant who is a nursing student Explanation: The nurse should avoid delegating this client to the nursing assistant who is a nursing student. Suctioning and the associated evaluation of the client would be within the scope of practice of the registered nurse, licensed practical nurse, and the senior nursing student present for clinical.

Which elements are common to any type of plan of care? Select all that apply.

Nursing diagnoses Client goals Nursing interventions Explanation: Regardless of type, the plan of care usually contains three key elements: the nursing diagnosis (client problem), client goals, and nursing interventions (nursing orders, nursing actions). Nursing plans of care need not necessarily include the client's past medical history or medical diagnoses.

A registered nurse (RN) and a licensed practical nurse (LPN) are caring for a client who has been admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing actions can the RN delegate to the LPN? Select all that apply.

Obtaining pulse oximetry Auscultating breath sounds Administering an oral antibiotic Explanation: It is within the scope of practice for a licensed practical nurse (LPN) to obtain pulse oximetry, auscultate breath sounds, and administer oral antibiotics. A registered nurse (RN) must perform the admission assessment and develop the nursing care plan. These are tasks that cannot be delegated because these are not in the scope of the LPN.

Which phase of the nursing process most involves establishing priorities?

Outcome identification and planning Explanation: During outcome identification and planning, the nurse establishes priorities as well as client goals and outcomes. During this phase, the nurse also plans nursing interventions and writes the plan of care. Assessment involves data collection; diagnosis involves identifying client problems. Implementation involves putting the plan of care into action.

Which statement on a plan of care should a nurse identify as a nursing intervention?

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

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. Explanation: A patient who presents with severe dizziness needs a comprehensive assessment, including vital signs and blood glucose level, prior to any other action. The results of the assessment could help determine which actions to take next. Discussing the need to change positions slowly and home blood pressure monitoring may be appropriate educational activities for this client, but the assessment should be performed first to be sure that the client's symptoms are caused by hypotension. The client may also need intravenous fluids to help correct hypotension, but the client must be assessed first.

The nurse is assessing the self-care capabilities of a client who will be discharged from the hospital. Which are barriers this client will likely face in meeting established nursing goals pertaining to self-care? Select all that apply.

Poor communication skills Inadequate emotional coping skills Debilitating illness Family's lack of interest in the plan of care Explanation: Barriers to goal attainment may involve the client, family members or significant others, or the nurse or other health care team members. Factors such as communication, health, motivation, emotions, and coping skills can be powerful barriers to adherence to treatment. Referrals to specialists would faciliate self-care, not be a barrier to it.

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?

Process evaluation Explanation: Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Process evaluation focuses on the nature and sequence of activities carried out by nurses implementing the nursing process, such as the timing of nursing care plan creation. Outcome evaluation focuses on measurable changes in the health status of clients. Structure evaluation focuses on the environment in which care is provided. There is no "design evaluation."

Which are correctly written nursing interventions? Select all that apply

Provide 5 to 6 small meals daily. Reposition the client from side to side every hour around the clock. Provide opportunities for the client to express concerns and verbalize feelings. Explanation: Nursing interventions are nurse-centered, action-oriented, and describe specifically what the nurse is doing (how, when, where, how often, how long, or how much). Providing 5 to 6 small meals, repositioning the client, and providing opportunities for expression of concerns and feelings are correctly written interventions. "Understand" and "know" are vague and are not action-oriented; it is unclear who is to perform these actions. Medication side effects and signs/symptoms of infection represent content that the nurse should know and teach to clients.

Which nursing actions reflect the implementing step of the nursing process? Select all that apply.

Providing health education to reduce health risks Referring the client to community resources, when necessary Using evidence-based interventions individualized for the client Explanation: Examples of the implementing step include using evidence-based interventions individualized for the client; providing health education to reduce health risks; and referring the client to community resources, when necessary. Selection of nursing interventions occurs in the planning step. Determining the client's response to nursing interventions occurs in the evaluating step.

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 Explanation: Supportive nursing interventions emphasize the use of communication skills, relief of spiritual distress, and caring behaviors such as touch. Some clients and families respond to stress by joking, teasing, or laughing about it. They may use humor as a way to relieve stress. A client may say jokingly, "Gee, my arm must be target practice for everyone learning how to draw blood." Technical is supporting the client by using medical jargon to explain medical procedures. Coordinating to bringing in additional resources for the client.

For the second time this week, a nurse reports to the nurse manager failing to perform an ordered dressing change due to a lack of time. The nurse manager recognizes that the nurse normally is very punctual and known to provide good care for clients and that the unit census has been very high this week. However, the nurse manager knows that quality care must be provided and reports this occurrence. Which approach to quality assurance does this scenario represent?

Quality as opportunity Explanation: Quality as opportunity is focused on finding opportunity to improve quality through teamwork and sharing in a nonthreatening environment. Mistakes are seen as a breakdown in the system rather than a lack of motivation or sign of incompetence in the nurse. Quality by inspection focuses on finding deficient workers and removing them. Quality by design and quality as promotion are not specific approaches to quality assurance. Reference:

Which statement regarding quality improvement or quality assurance is correct?

Quality improvement focuses on processes, data, and statistical thinking. Explanation: Quality improvement focuses on processes, data, statistical thinking, and client satisfaction and promotes empowerment and collaboration. Quality assurance focuses on organization structure and individuals and is externally driven.

Which is is the priority activity for the nurse to perform in the implementation step of the nursing process?

Reassess client's needs. Explanation: The activities of implementation in order of priority are: (a) reassess, (b) set priorities, (c) perform nursing interventions, (d) record nursing actions. Differentiation between subjective and objective data is most associated with the assessment phase of the nursing process.

A nurse manager is preparing for a visit from The Joint Commission. The nurse manager determines that this visit reflects which type of evaluation?

Retrospective evaluation Explanation: Nursing care and client outcomes may be evaluated while the client is receiving care (i.e., a concurrent evaluation) or after the client has been discharged (i.e., a retrospective evaluation). The type of retrospective audit most familiar to nurses working in hospitals is the Joint Commission retrospective chart review. Quality-assurance programs are special programs that promote excellence in nursing. These range from small programs conducted by nurses on a nursing unit to those developed for an entire institution, state, province, or country. Quality improvement (QI)—also known as continuous quality improvement [CQI] or total quality management [TQM]—consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted client groups.

The registered nurse (RN) is delegating the task of assisting a postoperative client to the bathroom to the unlicensed assistive personnel (UAP). The nurse witnessed the UAP correctly perform the task on previous occasions and knows the UAP is competent to perform the task. The nurse has communicated how to get the client out and back into bed and told the UAP not to allow the client to bear weight on the left leg. The nurse validated that the activity was completed and gave the UAP feedback. Which delegation guideline did the nurse omit?

Right circumstance Explanation: The nurse fails to follow the delegation guideline related to right circumstance. The RN did not assess the client's needs or identify the outcome to be achieved by the task that was delegated. The other guidelines were followed.

The nurse is interviewing an 80-year-old client admitted to the hospital for evaluation of diabetes. The client reports enjoying being in the hospital because the client lives alone and does not have many friends. The client reports having a spouse die 1 year ago and no longer being able to drive. The client relies on a daughter, who lives one hour away, to shop for the client once a week. The client states, "My daughter can never stay long and is just in and out in no time." Which nursing diagnoses would be appropriate for this client? Select all that apply.

Risk for Loneliness Powerlessness Explanation: Living alone and having to rely on family for help with necessities support the diagnoses of Powerlessness and Risk for Loneliness. The client has offered no indication of concern about body image, memory, or low self-esteem.

When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data?

Safety and security Explanation: Physiologic needs are the physical requirements for human survival. Physiologic needs include breathing, water, food, sleep, clothing, shelter, and sex. Once a person's physiologic needs are relatively satisfied, the person's safety needs take precedence and dominate behavior. Safety and security needs include personal security, emotional security, financial security, health and well-being, and safety against accidents or illness and their adverse impacts. After physiologic and safety needs are fulfilled, the third level of human needs is interpersonal and involves feelings of love and belonging. These include relationships with friends, intimacy, and family. Self-esteem needs are ego needs or status needs, such as for getting recognition, status, importance, and respect from others. All humans have a need to feel respected; this includes the need to have self-esteem and self-respect. Self-actualization is what a person's full potential is and the realization of that potential.

Which action should the nurse perform during the planning step of the nursing process?

Selects nursing measures, including client education Explanation: During the planning phase of the nursing process, the nurse establishes priorities, identifies and writes expected client outcomes, selects evidence-based nursing interventions, and communicates the plan of nursing care. The nurse interprets and analyzes the data and identifies client strengths and weaknesses during the diagnosis phase of the nursing process. Establishment of a database occurs during the assessment phase.

Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal?

Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. Explanation: 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.

What are the advantages of using standard Nursing Interventions Classifications (NIC)? Select all that apply.

Teaching decision making Allocating nursing resources Developing information systems Communicating nursing to non-nurses Explanation: Each of the interventions listed in the NIC has a label, a definition, a set of activities that a nurse performs to carry out the intervention, and a short list of background readings. This information encourages the teaching of decision making to new nurses and helps administrators plan more effectively for staff and equipment needs (nursing resources) and examine the effectiveness and cost of nursing care. The NIC also promotes communication of the nature of nursing to the public. The goal is not to limit but to encourage reimbursement for nursing services. The NIC allows for a standardized nomenclature rather than multiple systems of nomenclature.

A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client?

The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. Explanation: Long-term outcomes require a longer period (usually more than a week) to be achieved than do short-term outcomes. They also may be used as discharge goals, in which case they are more broadly written and communicate to the entire nursing team the desired end results of nursing care for a particular client. Resumption of ADLs in the home setting is characteristic of a long-term outcome. Explaining energy-conservation techniques, mobilizing in the hospital, and demonstrating correct medication administration are short-term outcomes that may be accomplished prior to

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. Explanation: Standards are the levels of performance accepted and expected by the nursing staff and other health team members, such as institutional policies and procedures. The nurse preceptor providing feedback to the new graduate nurse after 6 weeks of orientation is an example of peer review. The nurse manager providing the staff nurse feedback regarding job performance for the previous year is typical of an annual employee review. The nurse seeking input from the UAP on a family's response to education is inappropriate, as the nurse may not delegate evaluation to the UAP.

The nursing team, consisting of a nurse and experienced unlicensed assistive personnel (UAP), have worked well together for the past year. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made?

The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. Explanation: The nurse failed to communicate clear instructions to the UAP. The delegated tasks are not too numerous and are within the scope of a UAP's role and responsibilities. The nurse has had ample opportunity to validate the UAP's knowledge and skill to perform the tasks, as they have worked together for the past year.

Which purpose of the evaluation phase of the nursing process is a priority during client care?

To examine the client's behavioral response to the care received Explanation: During evaluation, nurses continually assess responses of clients to particular nursing interventions, establish different priorities for nursing diagnoses, and alter plans of care as necessary. During client care, the priority purpose of evaluation is to examine the client's behavioral response to the care received. After that, the nurse may need to establish different priorities for nursing diagnoses and alter the plan of care. Appraising the collaboration of the client and family is a type of evaluation but is not necessarily the priority in all situations. Limiting assessment to the first phase of the nursing process is not a purpose of the nursing process.

What are the goals of the research that is behind the Nursing Outcomes Classification (NOC) system? Select all that apply.

To identify, label, and validate nursing-sensitive client outcomes and indicators To evaluate the validity and usefulness of the classification in clinical field testing To define and test measurement procedures for the outcomes and indicators Explanation: The goals of research behind the NOC are to identify, label, validate, and classify nursing-sensitive client outcomes and indicators; evaluate the validity and usefulness of the classification in clinical field testing; and define and test measurement procedures for the outcomes and indicators. This research continues in an effort to develop a common nursing language to optimize the design and delivery of safe, high-quality, and cost-effective care. Teaching decision making and ensuring proper reimbursement are not goals of the NOC. Communicating nursing to non-nurses is a goal of the Nursing Interventions Classification (NIC).

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is:

a guideline. Explanation: A guideline is defined as a broad, research-based practice recommendation that may or may not have been tested in clinical practice. An algorithm has intense specificity and provides no provider flexibility; it is used to manage high-risk groups within a cohort. A critical pathway represents a minimal practice standard for a specific client population. An order set includes preprinted provider orders used to expedite the order process.

A nurse sees the client grimace and documents that the client is in pain, without interviewing the client to obtain further cues. The nurse has:

a lack of cues, or premature closure. Explanation: The lack of adequate cues is called premature closure, which is the case in this situation, as the nurse only has one cue. There is no "cluster" of cues to interpret, so impaired cluster interpretation would not be accurate. It is not so much that the nurse's database is ineffective as it is that the database lacks sufficent data. Evaluation is a separate phase in the nursing process and does not pertain to diagnosis.

When collecting subjective and objective data for a database in a client's home, it is important to:

ask the client to turn off the television. Explanation: When collecting data for a nursing history and assessment in the home environment, distractions such as a television should be minimized. It is not required or appropriate to have a social worker verify your information, nor is it necessary to evaluate the care provided by the physician. There may be an isolated scenario requiring a 24-hour dietary recall, but this would certainly not be routine.

The expected outcome for a client with a new diagnosis of osteoporosis is "Client will implement actions to promote safety and bone strength." Which statement by the client is the best indicator that the outcome expectations have been met?

"I walk daily wearing low-heeled shoes." Explanation: The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new diagnosis must learn appropriate actions for care. With osteoporosis the most important means to prevent further bone loss is weight-bearing activity, such as walking. While each option is appropriate for a client with osteoporosis, only one includes both components of the outcome. Activities that prevent falls, such as wearing low-heeled tie shoes, turning on lights, and removing scatter rugs, are important for safety.

A client reports to the nurse quitting smoking 6 months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome?

Affective Explanation: Affective outcomes pertain to changes in client values, beliefs, and attitudes and are more complex to evaluate. Changes in behaviors, such as the cessation of smoking or nutritional changes that lead to weight loss, are examples of affective outcomes. Cognitive outcomes involve an increase in client knowledge and are evaluated by asking the client to repeat information. Psychomotor outcomes describe the client's achievement of a new skill and are evaluated by having the client perform the skill. Physiologic outcomes result in physical changes and are evaluated through physical assessment.

A nurse is caring for a client admitted for bowel obstruction, which now has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply.

Auscultate for bowel sounds. Begin feedings with clear broth. Consult with a dietitian regarding appropriate foods. Explanation: Feedings should begin slowly with clear liquids as the first food. Immediately resuming a standard diet after a period of having nothing by mouth is likely to result in gastrointestinal distress. It is appropriate for the nurse to monitor bowel sounds and to consult with the dietician.

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?

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

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?

True collaboration Explanation: This scenario represents true collaboration, as nurses and other health care team members are demonstrating mutual respect, shared responsibility, and shared decision making. Although skilled communication and effective decision making are likely to be involved in true collaboration, these are not the focus of this scenario. There is no evidence of whether staffing is appropriate in this scenario.