Med Surg I Final W

A new graduate is assigned six clients to care for on a medical unit. Without asking anyone for help, by the end of the shift, the nurse is visibly upset and states, "I cant do this anymore." What characteristic of critical thinking has the nursing not developed? A. Show confidence B. Aware of their own limitation C. Humble D. Willing to persevere

Aware of their own limitation

The RN has developed the plan of care for a client and shares the plan with the LPN. What can the LPN provide in the implementation phase for this client? Select all that apply A. Basic therapeutic and preventive nursing measures B. Manages client care such as delegation C. Provides client and family teaching D. Records and exchanges information with healthcare team

Basic therapeutic and preventive nursing measures Provides client and family teaching

The LPN is collecting data so that the RN may develop the plan of care for the client. What is the importance of accurate gathering of baseline data? A. The physician will be able to make a diagnosis B. A comparison for future signs and symptoms C. The RN will be able to make the assignments based on the baseline data D. The RN will know what type of medication the client will receive.

A comparison for future signs and symptoms

The nursing student says to the instructor. " I always hear about critical thinking and how to develop it. How will this benefit me as a nurse?" What is the best response by the instructor? A. If you have critical thinking skills, you wont make mistakes B. You will never make it through nursing school without those skills C. Without good critical thinking skills, you wont be able to make a decision D. Acquiring critical thinking skills will help you become more efficient and effective at resolving problems

Acquiring critical thinking skills will help you become more efficient and effective at resolving problems.

The nurse gathers data for a client who has dehydration and formulates a nursing diagnosis of Fluid Volume Deficit related to diarrhea and vomiting as evidenced by poor skin turgor, lethargy, and altered fluid and electrolyte balance. What type of nursing diagnosis is identified with this client? A. Risk nursing diagnosis B. Syndrome diagnosis C. Health promotion nursing diagnosis D. Actual nursing diagnosis

Actual nursing diagnosis

A client complaints of chest pain. What part of the nursing process does the LPN understand the RN is performing? A. Planning B. Implementation C. Evaluation D. Assessment

Assessment

The nurse is developing a concept care make for a client with multiple medical problems. What would the nurse take as the first step in developing and using a concept care map? A. Assessment B. Assessment/Diagnosis C. Diagnosis/Planning D. Planning/ Implementation

Assessment

The LPN is assisting with admission of a client scheduled for surgery the next day. What role does the LPN have in the planning phase of the nursing process? A. Gathers more extensive biopsychosocial data B. Draws conclusions, uses judgment, and makes diagnosis C. Establishes priorities, sets short- and long- term goals D. Contributes to the development of care plans

Contributes to the development of care plans

The student nurse is developing a concept care map for her client with multiple sclerosis. In what phase does the student determine the relationship among the nursing diagnosis and begin to see the client holistically? A. Assessment B. Assessment/Diagnosis C. Diagnosis/Planning D. Planning/Implementation

Diagnosis/Planning

Which of the following pieces of information is included in the client database? A. Nursing care B. Diagnostic studies C. Plan of care D. Collaborative problems

Diagnostic studies

Which of the following is an important element of implementation? A. Client database B. Critical thinking C. Nursing orders D. Documentation

Documentation

Which of the following is involved in the implementation step of the nursing process? A. Selecting nursing interventions B. Documenting nursing care and client responses C. Documenting the plan of care D. Identifying measurable outcomes

Documenting nursing care and client responses

Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes? A. Assessment B. Planning C. Implementation D. Evaluation

Evaluation

Which type of nursing diagnosis has a goal to increase well-being and enhance specific health behaviors? A. Health promotion B. Risk C. Wellness D. Actual

Health promotion

Which type of nursing diagnosis statement begins with the stem readiness for enhanced and does not include related factors or supporting data? A. Health promotion B. Syndrome C. Risk D. Actual

Health promotion

The nurse is developing a care plan for a client who has had a stroke and is unable to assist with care at this time. Which problem would the nurse deem a top priority? A. Risk for development of a pressure ulcer B. Risk for injury C. Ineffective breathing pattern D. Social isolation

Ineffective breathing pattern

The LPN states to an RN "I dont know why we have to follow a care plan. Noone even uses it, and it just means more paperwork. Whats the purpose?" What is the best response by the RN? A. "I agree with you, and we should talk to the manager about eliminating them from our required paperwork" B. "I think it is something we have always done, and we have to continue to use them." C. "It helps to provide a systematic method for us to plan and implement care so that we achieve positive outcomes." D. "Physicians use our care plans in order to see what we are doing for the clients."

It helps to provide a systematic method for us to plan and implement care so that we achieve positive outcomes.

Which of the following is a true statement about critical thinking in nursing? A. It involves purposeful, outcome-directed thinking. B. It shows trends and patterns in client status. C. It makes judgements based on conjecture. D. It supplies validation for reimbursement.

It involves purposeful, outcome-directed thinking

Which of the following is a true statement about critical thinking according to Alfaro-LeFevre? A. It makes judgements based on conjecture B. It is based on the medical model C. It considers only the clients needs D. It is guided by professional standards and code of ethics

It is guided by professional standards and code of ethics.

The nurse understands that one of the characteristics of critical thinking is flexibility. What can the nurse do to achieve this characteristic? A. Listen to new ideas and other viewpoints B. Modify priorities and adapt to change C. Accept that answers may not come easily D. Foresee probable outcomes

Modify priorities and adapt to change

The RN determines the interventions for a client with pneumonia and writes them in the written plan as nursing orders. What would be an appropriate nursing order for this client? A. Force fluids B. Offer the client 100 mL of fluid every hour while awake C. Offer fluids PRN D. Give adequate amounts of fluid throughout the day

Offer the client 100 mL of fluids every hour while awake.

The RN develops an outcome standard of "client will ambulate with an assistive device 60 feet with assistance twice a day" for a patient who had a hip replacement. What part of the nursing process is involved with this outcome statement? A. Assessment B. Planning C. Implementation D. Evaluation

Planning

The LPN plays a vital role in the development of a nursing diagnosis for a client. What role does the LPN have? A. Report information that suggests actual or potential health problems. B. Examine and analyze the client database to formulate a nursing diagnosis C. Inform the physician about the specific development of the nursing diagnosis D. Evaluate the effectiveness of the nursing diagnosis and how it pertains to the data collected

Report information that suggests actual or potential health problems

A client has a nursing diagnosis of Risk for Impaired Skin Integrity related to prescribed bed rest and decreased sensation and mobility of the lower extremities. What type of nursing diagnosis is the classified as? A. Actual diagnosis B. Health promotion diagnosis C. Risk diagnosis D. Syndrome diagnosis

Risk diagnosis

The nurse is prioritizing the care of a client who has had a diagnosis of uncontrolled diabetes and may have the left foot amputated related to a nonhealing ulcer. What need would the nurse place at the lowest level while prioritizing the clients care? A. Physiologic needs B. Safety and security needs C. Love and belonging needs D. Self-actualization needs

Self- actualization needs

Which of the following is the highest level of human need according to Maslow? A. Physiologic B. Love and belonging C. Esteem and self-esteem D. Self- actualization

Self-actualization

Which of the following identify a diagnosis associated with a cluster of other diagnosis? A. Risk nursing diagnosis B. Actual nursing diagnosis C. Syndrome diagnosis D. Health promotion

Syndrome diagnosis

A client is being admitted to the medical floor, and the RN is too busy to do the full assessment. The RN delegates the LPN to care for the patient until the RN can see the patient. What function i within the scope of practice for the LPN? A. The LPN can gather the data B. The LPN can draw conclusions and use judgement to make a diagnosis C. The LPN can establish priorities D. The LPN can manage the clients care.

The LPN can gather data

In order to establish specific and realistic outcomes so that the client does not become frustrated in trying to achieve them, who should be involved in establishing these outcomes? A. The client and family B. The physician C. The certified nursing assistant D. Case management

The client and family

A client being cared for by the healthcare team has a large open abdominal wound after having a surgical procedure. The wound had to be reopened due to the development of infection and is left to heal with packing and dressing changes twice daily. What would be an appropriate measurable short-term outcome for this client? A. The wound will heal before the client is discharged B. The client will change his own dressing twice a day C. The client will have no fever and no purulent discharge in 3 days D. Dressing changes will be done twice a day using aseptic technique

The client will have no fever and no purulent discharge in 3 days.

The nurse has developed a plan of care for a client who is having a surgical procedure and is at risk for the development of pneumonia. The nurse devises the outcome statement to read: "The client will have clear lungs by the third postoperative day." On the third postoperative day, the patient has left lower lobe crackles and infiltrates on the chest X-ray. What conclusion does the nurse reach for this client? A. The outcome is achieved, the problem is solved, and the nursing orders are discontinued. B. The outcome is not met, but progress is being made, and the plan of care is continued or revised with minor change. C. The outcome is not achieved, and the plan requires critical reevaluation and major revision D. The outcome will be reassessed in 2 more days.

The outcome is not achieved, and the plan requires critical reevaluation and major revision.

A client has been admitted to the hospital with a large sacral pressure ulcer. The physician orders the wound care protocol to be performed twice a day. What would be a statement on the plan of care that would address the implementation phase of the nursing process for this patient? A. A 6cm x 4cm wound with malodorous, yellow exudate B. The clients wound will heal by 1 cm by the end of 5 days C. The clients wound has healed by 0.5cm on day 3 of wound care D. Turn the client every 2 hours

Turn the client every 2 hours

The RN is attempting to formulate a nursing diagnosis for a client but does not find where the problem fits into a North American Nursing Diagnosis Association approved diagnosis. What is the best option for the nurse? A. Gather other data so that it will fit into a NANDA approved diagnosis B. The nurse will have to forgo applying a nursing diagnosis C. Pick a NANDA approved diagnosis as long as it somewhat fits D. Use his or her own terminology

Use his or her own terminology

A client is admitted to the hospital for control of diabetes mellitus. When does the LPN understand the nursing process begins? A. When the client enters the healthcare system B. Prior to the client being discharged C. After the RN initiates the plan of care D. When the physician writes the first order for care

When the client enters the healthcare system.