Prep U 14-18
Which piece of client information is subjective?
Correct response: Generalized myalgia or muscle pain Explanation: Symptoms such as muscle pain or myalgia are considered subjective cues in a client's health history, as only the client can determine its presence. Signs of illness, such as temperature, leukoplakia, and ptosis, are considered objective cues in a health history, as is a nurse observing that a client is not oriented to time or situation. Objective signs are observable, perceptible, and measurable.
The nurse is conducting a client interview and notices that the client answers every question with a "yes" or "no" response. What is most likely the cause of this action by the client?
Correct response: Pain Explanation: Clients often offer clipped responses and "yes" and "no" answers when in pain, as their main focus is pain relief. Sleepiness would be be observed if the client did not respond in a timely manner. A client with low anxiety is relaxed and would answer the question with intention and thoughtfulness. A hungry client would be short-tempered and angry.
The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?
Correct response: The client with continuous pulse oximetry who requires pharyngeal suctioning. Explanation: The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to *evaluate the client's response in pulse oximetry to the suctioning*. The nurse can delegate the other clients to the unlicensed assistive personnel.
The nurse is collecting data from a client during a complete assessment. Which skill is the nurse demonstrating when documenting the assessment data?
You Selected: Collection Correct response: 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.
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?
You Selected: Review with the client the risks and benefits of surgery. Correct response: 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.
During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action?
Correct response: Go to the client and assess the client's pain. Explanation: The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment.
A nurse is evaluating the outcome of the plan of care after teaching a client how to prepare and administer an insulin pen. Which type of outcome is the nurse addressing?
You Selected: Cognitive Correct response: Psychomotor Explanation: Preparing and administering an insulin pen is a psychomotor outcome. Psychomotor outcomes describes the client's achievement of *new skills*. Cognitive outcomes describe increase in client *knowledge or intellectual behaviors*. Affective outcomes describe changes in client values, beliefs, and attitudes. Physiologic outcomes are concerned with how the human body works.
A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?
You Selected: Ongoing Correct response: Ongoing Explanation: Ongoing planning is carried out by any nurse who interacts with the client following admission and before discharge, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting. Outcome planning is not a specific type of nursing planning, although it would most likely be performed as part of initial planning.
The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?
You Selected: "Please tell me your thoughts about treating this diagnosis." Correct response: "Please tell me your thoughts about treating this diagnosis." Explanation: In the planning stage of the nursing process, the nurse must focus on the client's interests and preferences, keep an open mind, and include interventions that are supported by research. While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client's choices must be included in the plan for it to be successful. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care.
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?
You Selected: "Why do you feel that way about your cancer diagnosis?" Correct response: "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.
A client comes to the emergency department with a productive cough and an elevated temperature. Which type of assessment would the nurse most likely perform on this client?
You Selected: Emergency Correct response: Focused Explanation: In a focused assessment, the nurse gathers information about a specific problem that has already been identified. A head-to-toe assessment is an initial, complete assessment, typically to assess for any problems that have not been identified yet. An emergency assessment is used to identify a life-threatening problem. A time-lapse reassessment is scheduled to compare current status with the baseline obtained earlier.
A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?
You Selected: Nurse case manager Correct response: Nurse case manager Explanation: 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.
During admission, a teenage client who has a diagnosis of anorexia informs the nurse of a 5-pound weight loss within the last 6 months. What should the nurse do with this data?
You Selected: Record it in the client's record. Correct response: Validate the weight loss with the client. Explanation: When a client reports data that appear to be distorted, either intentionally or unintentionally, the nurse—to ensure accuracy—needs to continually verify and validate all data. It would not be appropriate to tell the client the data are not correct or to ignore the data, as doing either could undermine the client's trust in the nurse and/or cause conflict with the client. The nurse should not just document this information, as it needs to be validated.
When collecting subjective and objective data for a database in a client's home, it is important to:
You Selected: ask the social worker to verify the collected data. Correct response: 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 nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?
Correct response: "Please tell me your thoughts about treating this diagnosis." Explanation: In the *planning stage* of the nursing process, the nurse must focus on the *client's interests and preferences*, keep an open mind, and include interventions that are supported by research. While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client's choices must be included in the plan for it to be successful. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care.
A nurse is conducting an interview with a client who reports abdominal distress. What is an appropriate interview question for this client?
Correct response: "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.
A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?
Correct response: Another registered nurse with critical care certification Explanation: Peer review is the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. Therefore, another registered nurse who is certified in critical care would be appropriate to evaluate a critical care nurse certified in critical care. A nurse manager and a critical care physician are at a higher level in the hierarchy than a staff nurse certified in critical care. A staff nurse without certification in critical care would also not be appropriate to evaluate a nurse with this certification.
Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer?
Correct response: By discharge, the client will perform hand hygiene before and after port care. Explanation: Outcomes should be specific, measurable, attainable, realistic, and timebound. Demonstrating hand hygiene before and after port care is a specific and reasonably attainable goal. The other answer options lack at least one of these criteria. 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."
A nurse plans a series of muscle-strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. The client is unsuccessful when the new strategies are implemented. Which action by the nurse may have led to failure to meet the outcome?
Correct response: Choosing actions that do not solve the problem Explanation: Common problems with planning nursing care include *failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. In this case, ALS is a progressive degenerative neuromuscular disorder. It is unrealistic to expect the client to regain abilities that are lost.*
A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?
Correct response: Ongoing Explanation: Ongoing planning is carried out by any nurse who interacts with the client following admission and before discharge, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting. Outcome planning is not a specific type of nursing planning, although it would most likely be performed as part of initial planning.
When assessing the firmness of a client's abdomen, the nurse should use which assessment technique?
Correct response: Palpation Explanation: Physical assessment skills of the nurse include auscultation, percussion, inspection, and palpation. Palpation is the use of touch to assess a client. It would be appropriate for assessing the firmness of the client's abdomen. None of the other assessment skills would allow the nurse to assess the firmness of the client's abdomen. Inspection is the use of visual observation to assess a client. Percussion is the use of striking with the fingers against the client's body to assess a client. Auscultation is the use of a stethoscope to assess body sounds within the client, such as heart and lung sounds.
The nurse is assessing a client in an outpatient setting. The client states,"I don't want to live anymore. My family hates me, and I am so tired of being sick. I have a gun, and I am seriously thinking of killing myself." The client reports a 30-year heavy smoking habit and having a cough for about 6 months. Ascultation reveals diminished breath sounds in the right upper lobe. The abdomen is distended with diminshed bowel sounds. The client's lips are slightly bluish in color. Which is the priority nursing diagnosis for this client?
Correct response: Risk for Suicide Explanation: The client who talks of suicide and has a plan to implement it should be taken seriously, making this the priority diagnosis. The other choices are important but could be addressed after making interventions for suicide prevention.
The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?
Correct response: The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years. Explanation: If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan.
A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem?
Correct response: The client is able to explain when and why the client needs to check the blood glucose level. Explanation: The ability to *describe the rationale and technique* for blood glucose monitoring indicates that the client has achieved a *cognitive* outcome. Demonstration of the technique constitutes a psychomotor outcome, whereas the expression of a desire for change is an *affective* outcome. The maintenance of healthy blood blood glucose levels is a physiologic outcome.
When reviewing the client's history, the nurse notes that the client's last documented bowel movement was 2 days ago. Before the nurse identifies a diagnosis of "Constipation," what assessment must the nurse make?
Correct response: The nurse should determine the client's normal bowel elimination pattern. Explanation: To validate the diagnosis, the nurse must *determine what is normal* for the client. Dietary habits may contribute to constipation, but the nurse must first confirm that the client is actually constipated. Likewise, *bowel sounds might help explain the cause of constipation, but the nurse should first confirm that the client is constipated*. There is no standard elimination pattern; it is highly individualized.
An older adult client who has been living in an assisted living facility for several months informs a visiting family member that a nurse is coming to do some kind of checkup. Which type of check would be most appropriate for the nurse to perform on this client?
Correct response: Time-lapsed assessment Explanation: A time-lapsed assessment is scheduled to compare a client's current status to the baseline data obtained earlier. Most clients in residential settings and those receiving nursing care over longer periods of time are scheduled for this type of check. An emergency assessment is conducted if the client is having an emergency such as chest pain or hemorrhaging from the hand. Focused assessment is performed on clients focusing on the system or systems involved in the client's problem. Developmental stage assessment is the process of mapping a child's performance compared with children of similar age.
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
Correct response: discharge planning. Explanation: Discharge planning begins at the time of admission with the nurse teaching the client and family specific skills necessary for self-care behaviors in the home. Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning. Initial planning is done at time of admission based on the nurse's admission assessment. Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship.
Which type of nursing intervention is oxygen administration and why is it considered to be so?
You Selected: An independent nursing intervention, because nurses have the necessary skill to administer oxygen Correct response: A dependent nursing intervention, because oxygen is considered a drug that requires a physician's order Explanation: Oxygen administration is a dependent nursing intervention because it requires a physician's order. Independent nursing interventions are autonomous actions based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnosis and expected outcomes. Nursing-initiated interventions, such as teaching, providing fluids, and assisting with guided imagery, do not require a physician's order. Collaborative and interdependent are not types of nursing interventions.
The nurse should evaluate client outcomes at which time?
You Selected: As early as possible Correct response: As early as possible Explanation: Nurses should evaluate client outcome achievement as early as possible. Celebrating outcome attainment with the client usually helps encourage the client and leads to further outcome achievement. When failure to meet designated outcomes is detected early, the care plan can be modified to remedy the failure. Waiting until the day of discharge may be too late. Evaluting outcomes after the client has been discharged would be difficult. Evaluating outcomes within 24 hours may be too soon or unnecessarily late, depending on the nature of the outcomes.
A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?
You Selected: As soon as possible after the client's surgery Correct response: On the client's admission to the hospital Explanation: Discharge planning should begin when a client is admitted for treatment. All the other times listed are too late and are not consistent with a client who is able to understand the process of the hospitalization.
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?
You Selected: Ask significant family members about the client's usual breathing pattern at home. Correct response: 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.
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?
You Selected: Chart the data. Correct response: Validate the data. Explanation: Data need to be validated when there are discrepancies (e.g., the client says there is no pain but the nonverbal behavior indicates that the client is experiencing pain). The nurse should not ignore the client's answer or the client's nonverbal behavior. The nurse should chart the assessment, but the priority is to validate the differences in the verbal communication and nonverbal behavior.
A nurse documents the following in the client chart: Risk for Decreased Cardiac Output related to myocardial ischemia. This is an example of what aspect of client care?
You Selected: Collaborative problem Correct response: Nursing diagnosis Explanation: The nursing diagnosis statement is worded by stating the client problem (using NANDA-I approved diagnoses) that the nurse is able to treat followed by the etiology of the problem. Nursing assessment refers to the collection of data. A medical diagnosis identifies diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness. Nurses cannot treat medical diagnoses independently. Collaborative problems are the primary responsibility of nurses. Unlike nursing diagnoses, with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines.
Discharge plans for a client with a mental health disorder include living with family members. The nurse learns that the family is no longer willing to allow the client to live with them. What is the nurse's most appropriate action?
You Selected: Communicate with the physician about additional orders. Correct response: Collaborate with other disciplines to revise the discharge plans. Explanation: The discharge needs of this client are complicated, and the nurse will need the assistance of other disciplines to make a successful discharge plan. The client should have input into the future living arrangements, but the client does not have the resources to make the arrangements alone. The physician may be involved in the discharge plan, but additional orders are not necessary. It is not true (and would be inappropriate) to tell the family that discharge plans cannot be changed. If the family is unwilling to take the client, the placement will be unsuccessful.
Which component of a nursing diagnosis gives additional meaning to the nursing diagnosis?
You Selected: Composition Correct response: Descriptors Explanation: Descriptors are words used to give additional meaning to a nursing diagnosis through adding conditions and showing relationships between events. The other answers listed are not components of a nursing diagnosis.
A nurse is assessing a client admitted to the hospital with reports of difficulty urinating, bloody urine, and burning on urination. What is a priority assessment for this client?
You Selected: Conducting a thorough systems review to validate data on the client's record Correct response: A focused assessment of the specific problems identified Explanation: The priority assessment at this time is a focused assessment of the client's primary concern. A focused assessment may be performed during the initial assessment if the client's health problem is apparent. A full assessment of the urinary system may be appropriate but is not the priority. A detailed assessment of the client's sexual history is not warranted, and although a thorough systems review is conducted, it is not the priority at this time.
The nurse on a busy acute care floor identifies that several clients with heart failure are being readmitted within 2 weeks of discharge. Which step in performance improvement is the nurse demonstrating?
You Selected: Discovering a problem Correct response: Discovering a problem Explanation: *Discovering the problem by detecting that there are several readmissions with heart failure is the first step in the process of performance improvement. The next step would be to plan a strategy using indicators, which includes calling an interdisciplinary meeting. The team would then implement a change and, lastly, assess whether the change was effective*.
Which action should the nurse take during the evaluation phase of the nursing process?
You Selected: Document reassessment of pain after medication administration. Correct response: 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 nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?
You Selected: Maintenance Correct response: Surveillance Explanation: Surveillance nursing interventions include detecting changes from baseline data and recognizing abnormal responses. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Maintenance nursing interventions involve the nurse assisting the client with performing routine activities of daily living. Supportive nursing measures involve providing basic comfort and emotional care to the client. Collaborative nursing interventions involve cooridination and communication with health care professionals in other fields to meet the client's needs.
A nurse is performing an assessment on a client in which the nurse categorizes the data according to various categories of functions. Which assessment model is the nurse using?
You Selected: Maslow's hierarchy Correct response: Gordon's functional health patterns Explanation: Systematic guidelines for nursing assessments help ensure that comprehensive, holistic data are collected. Gordon's functional health patterns model identifies 11 functional health patterns and organizes data within these patterns. Maslow's hierarchy has five levels of human needs, such as food, water, and shelter, and organizes data accordingly. A medical model organizes data collection by body system. There is no assessment model known as the prevention model.
During the interview component of the health assessment, how does the nurse convey to the client that the information is important?
You Selected: Nodding frequently during the interview Correct response: Sitting at eye level with the client Explanation: When the client responds to a question, the nurse conveys interest by maintaining eye contact, occasionally nodding, or verbally responding to the client's remarks. This is best accomplished by selecting a seat at eye level to allow direct engagement with the client during the interview. Standing during the interview can limit the interaction between nurse and client. Questions should be open-ended to elicit the most information and engage the client. Yes or no (close-ended) questions do not encourage the client to provide the level of detail the nurse is attempting to collect.
The nurse is caring for a postoperative client who is receiving morphine sulfate for pain management. The nurse obtains the following vital signs: heart rate, 74 beats/min; respiratory rate, 8 breaths/min; blood pressure, 114/68 mm Hg. After reviewing the nursing care plan and physician orders, the nurse administers naloxone. Which would allow the nurse to initiate this action?
You Selected: Order set Correct response: Standing orders Explanation: Standing orders allow the nurse to initiate actions that ordinarily require the order of a physician, such as administering naloxone. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. A protocol is a written plan that details nursing activities to be executed in specific situations. An order set is a preprinted set of provider orders that expedite the provider order process.
The nurse manager observes one of the unit nurses failing to wash hands on entering a client room. Hospital protocol is to wash hands before and after entering a client room. This scenario is an example of which approach to quality assurance?
You Selected: Quality as opportunity Correct response: Quality by inspection Explanation: Quality by inspection is an approach to quality assurance in which nurses watch for deficient workers and remove them in an effort to prevent harm to clients. Quality as opportunity, on the other hand, focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Quality by perception and quality as initiative are not specific approaches to quality assurance.
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?
You Selected: Receive a report from the nursing staff. Correct response: 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.
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?
You Selected: Report the nurse applying the restraints to the supervisor. Correct response: Confront the nurse and explain how this could be dangerous for the client. Explanation: Confronting the nurse and explaining the danger for the client is a form of peer evaluation. Peer evaluation involves evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. This is an important mechanism nurses can use to improve their professional performance; it can be done formally or informally. Reporting the nurse does not enhance a good working relationship and does not follow the chain of command. An incident report is not warranted at this point in time. The physician should not be contacted for an order unless it is decided that the restraint is going to be left on the client.
While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention?
You Selected: Surveillance Correct response: Surveillance Explanation: Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes, such as observing the appearance and characteristics of clients and hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states. Educational interventions require instruction, demonstration, and return demonstration of knowledge or a skill set. Psychomotor interventions involve the nurse physically working with the client. Maintenance interventions involve the nurse assisting the client with performing routine activities of daily living.
When caring for a client in the emergency room who has presented with symptoms of a myocardial infarction (MI), the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. For the nurse to be operating within the nurse's scope of practice, what conditions must be present?
You Selected: The nurse is operating under standing orders for clients with suspected MIs. Correct response: The nurse is operating under standing orders for clients with suspected MIs. Explanation: For the nurse to administer medications or order laboratory tests, the nurse must have a physician's order. In special circumstances, such as in the emergency room, there are standing orders in place to authorize the nurse's actions in certain situations. The other three statements may also be true, but they do not give the nurse the authority to institute these actions independent of a physician's order.
Which nurse is using criteria to determine expected standards of performance?
You Selected: The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation. Correct response: 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.
A nurse manager tends to use the quality by inspection method of ensuring quality on the unit. Which actions, taken by this manager, are evidence of use of this technique? Select all that apply.
You Selected: The nurse tries to make client rounds with the health care providers every morning. Correct response: The manager threatens to "write up" a nurse if the nurse is late to work again. The nurse requests transfer off the unit for a nurse who has made three medication errors in three months. Explanation: *Quality by inspection* focuses on finding deficient workers and removing them. Quality as opportunity focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork. Holding education sessions regarding problem-prone procedures reflects this technique. Not participating in celebrations and making client rounds are not related to either quality style.
What outcome does the nurse hope to achieve by evaluating the plan of care of a client who is being discharged?
You Selected: To allow the nurse to terminate the nurse-client relationship Correct response: To direct future nurse-client interactions Explanation: The purpose of evaluation is to allow the client's achievement of expected outcomes and, when necessary, to modify the plan of care to direct future nurse-client interactions. The plan of care encompasses more than the relationship between the nurse and the client. It is important to evaluate the achievements by the client. The nurse develops nursing diagnoses during the diagnosis phase of the nursing process, not the evaluation phase. Medical prescriptions are physician interventions, not nursing interventions, and thus would not be included in the nursing plan of care. The purpose or outcome of evaluating the plan of care is not to terminate the nurse-client relationship.
Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training?
You Selected: Validation is an important part of assessment. Correct response: All data collected need to be validated. Explanation: Validation is the act of confirming or verifying. The purpose of validation is to keep data as free from error as possible. It is an important part of assessment. However, it is neither possible nor necessary to validate all data; nurses should decide which items need verification.
While standing on the right side of the client, the nurse observes that the client does not respond when spoken to. After assessing the client the nurse charts, "The client's hearing may be impaired on the right side." This statement is an example of:
You Selected: a cue. Correct response: an inference. Explanation: The judgment a nurse makes about a cue is known as an inference. A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. The nurse can observe a cue directly, but not an inference. The key is the verb used —"hearing may be impaired." The statement is not erroneous or duplicate data.
The nurse is caring for a client who is experiencing a collaborative problem. The nurse should plan the client's care based on an understanding that this problem is characterized by:
You Selected: a result of disease, trauma, treatment, or diagnostic studies. Correct response: a result of disease, trauma, treatment, or diagnostic studies. Explanation: The collaborative problem results from disease, trauma, treatment, or diagnostic studies. Collaborative problems require physician-prescribed and nurse-prescribed actions. The medical diagnosis requires and provides physician-prescribed actions for treatment. A nursing diagnosis describes a risk or wellness human response to health problems. Collaborative problems may or may not require immediate action. They do not necessarily provide a convenient means of communication among team members.
During the preparatory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should:
You Selected: identify existing and potential health problems. Correct response: review as much information as possible. Explanation: The preparatory or preinteraction phase occurs when the nurse meets the client. The nurse should review as much information as possible about the client during this phase. It would be premature for the nurse to attempt to clarify the client's health status, identify nursing diagnoses, or develop a nursing care plan without having completed the client interview, nursing history, and nursing assessment, all of which happen later in the assessment process.
"The levels of performance accepted by and expected of nursing staff or other health team members" defines:
You Selected: standards. Correct response: standards. Explanation: *Standards* are the "levels of performance accepted by and expected of nursing staff or other health team members." *Criteria* are "measurable qualities, attributes, or characteristics that identify skill, knowledge, or health status." Evidence-based practice incorporates delivering nursing care that evidence supports as likely to result in meeting the expected client outcomes. Evaluation involves measuring how well the client has achieved the outcomes that were set forth in the plan of care.
When developing an appropriate nursing diagnosis, the nurse needs to keep in mind that:
You Selected: the signs and symptoms of the disease are part of the information conveyed. Correct response: the interventions planned must be within the nurse's scope of practice. Explanation: A nursing diagnosis describes an actual, risk, or health promotion response to a health problem that nurses are responsible for treating independently. Nursing diagnoses describe the client's response to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or interventions. Nursing diagnoses carry legal ramifications. Only health care problems within the scope of nursing practice may be identified as nursing diagnoses. A nurse may not diagnose a medical disease and is not licensed to independently treat such a problem. Medical diagnoses, not nursing diagnoses, require validation by the physician that the problem exists, are focussed on pathophysiologic responses of body organs and systems, and convey information about signs and symptoms of disease.