PREPU chapter quizzes for exam 1 ch 13

At 0730, the nurse notes that the client states that pain is a 7 on a scale of 0 to 10. Based on this assessment, the nurse administers pain medication to the client. At 0800, the nurse evaluates the client and finds that pain is a 4 on a scale of 0 to 10. Which example of documentation most clearly communicates the initial morning assessment? 0730: Client reports pain is a 7 on a scale of 0-10. Morphine sulfate 2 mg IV administered. 0730: Client states that pain is severe. Pain medication administered. 0900: Client states pain from 0730 has decreased from a 7 to a 4 after medication was administered. 0800: Client states that pain has decreased.

0730: Client reports pain is a 7 on a scale of 0-10. Morphine sulfate 2 mg IV administered.

Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)? Grip weakness in the right hand Crackles in bilateral lung bases A blood glucose level of 108 mg/dL A client report of shooting pain up the left leg

A client report of shooting pain up the left leg

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? Nutrition Self-perception Activity and rest Health promotion

Activity and rest

The nurse is caring for an underweight female client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client? Administer a high-calorie diet, excluding wheat, rye, and oats. Monitor for allergies. Administer a daily multivitamin. Weigh client as needed.

Administer a high-calorie diet, excluding wheat, rye, and oats.

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? Follow up with the client later to determine whether the client's laboratory test results improve. Analyze the data and create an individualized nursing diagnosis. Identify outcomes for the client with the client's input. Administer a prescribed medication to decrease the client's blood glucose level.

Analyze the data and create an individualized nursing diagnosis

A nurse demonstrates critical thinking when applying the nursing process to client care. Which behavioral components would the nurse likely use during the assessment phase? Select all that apply. Recognizing assumptions Recognizing issues Asking relevant questions Exploring ideas Interpreting evidence

Asking relevant questions Exploring ideas Recognizing issues

The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the most appropriate nursing action? Report it to the health care provider. Establish a nursing diagnosis of Altered Skin Integrity. Assess the client's back visually. Document the rash in the client's chart.

Assess the client's back visually.

Which step in the nursing process includes the careful taking of a history and a nursing examination? Planning Assessment Nursing diagnosis Implementation

Assessment

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which action best demonstrates the nursing skill of caring in this situation? Notifying the health care provider of lab results Assisting the client to sit up in a chair Assessing the abdominal incision Monitoring vital signs

Assisting the client to sit up in a chair

Nurses who embrace their role in securing client well-being are sensitive to the ethical and legal implications of nursing practice. Which attributes are examples of these ethical/legal skills? Select all that apply. Being trusted to act in ways that advance the interests of clients Working collaboratively with the health care team as a respected and credible colleague to reach valued goals Selecting nursing interventions that are most likely to yield the desired outcomes Being accountable for practice to oneself, the client, the caregiving team, and society Acting as an effective client advocate Using technical equipment with sufficient competence and ease to achieve goals with minimal distress to clients

Being trusted to act in ways that advance the interests of clients Being accountable for practice to oneself, the client, the caregiving team, and society Acting as an effective client advocate

Which statements are true about the implementation phase of the nursing process? Select all that apply. This phase promotes wellness and restores health. Implementation is the process of carrying out the plan of care. Implementation is only carried out by nursing professionals. Care provided during implementation should be documented in the client's chart. All interventions carried out during this phase must be accompanied by a physician's order.

Care provided during implementation should be documented in the client's chart. Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health.

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

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

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented? Clinical reasoning Reflection Caring Assessment

Clinical reasoning

The nurse is caring for a client in a critical care unit. The client's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac rhythm? Interpersonal and technical skills Interpersonal and ethical skills Cognitive and technical skills Cognitive and ethical skills

Cognitive and technical skills

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

Continuity of care can be provided to the client.

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

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

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? Administer an additional liter of intravenous fluids. Formulate a plan of care based on risk for dehydration. Check the client's skin turgor. Determine whether the prescribed treatment was effective.

Determine whether the prescribed treatment was effective.

A nurse identifies the following: "Impaired skin integrity related to immobility as evidenced by reddened areas on the sacrum." The nurse is most likely in which phase of the nursing process? Assessment Planning Diagnosis Implementation

Diagnosis

Which step of the nursing process involves reporting or analysis of data to identify and define health problems? Assessment Implementation Planning Diagnosis

Diagnosis

The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What should the nurse determine this phase will include? Select all that apply Only factors that positively affect the outcome should be identified during evaluation. Evaluations should be documented daily in the client's record. Evaluation does not involve client assessment. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care. Evaluation is the last part of the nursing process.

Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client's record. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.

A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply. Ineffective coping Heart failure Pneumonia Imbalanced nutrition Impaired mobility

Impaired mobility Imbalanced nutrition Ineffective coping

Giving medication occurs in which step of the nursing process? Assessment Planning Implementation Evaluation

Implementation

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next? Change the nursing diagnosis because the client's problem was falsely identified. Develop an additional nursing diagnosis to meet the client's health needs. Reassess the client for more symptoms of deficient fluid volume. Modify the plan of care and interventions to meet the client's needs.

Modify the plan of care and interventions to meet the client's needs

The nurse enters the room of an adult client who reports postoperative abdominal pain. The client states that the pain is severe but is relieved some when getting up to go the bathroom. Which is the nurse's best determination based on this assessment? Even with pain, the client is ambulatory and therefore ready for discharge. More assessment would be beneficial to determine whether pain medication is desirable. The client should not be ambulating with pain. The client's pain is really not that bad because the client can ambulate.

More assessment would be beneficial to determine whether pain medication is desirable.

Which statements are true about informatics in nursing practice? Select all that apply. Computers do not help with communication, but deter it because of the lack of personal interaction. Nurses should value technologies that support error prevention and care coordination. Utilization of information services helps to support decision making. Informatics only involves documentation of timely and accurate charting. The use of informatics can help manage knowledge and mitigate error.

Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. Utilization of information services helps to support decision making.

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process? Planning Evaluation Diagnosis Implementation

Planning

A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client? Keep resolved nursing diagnoses as part of the plan of care in case the related problems return. Do not allow the client to review the client's own nursing diagnoses. Prioritize the nursing diagnoses. Add a new nursing diagnosis in the nurse's own words to individualize the plan of care.

Prioritize the nursing diagnoses.

Which is the best example of person-centered care provided by a registered nurse? Administration of pain medication every 4 hours to a client who is postoperative Insertion of a nasogastric tube for gastric decompression Reassuring a client who is anxious about a procedure Development of a plan of care for a new admission

Reassuring a client who is anxious about a procedure

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain? Administering extra pain medication Repositioning the client Documenting opioid dependence Administering a placebo

Repositioning the client

Which are characteristics of one who has developed critical thinking skills? Resilient, authoritative, reactive, and private Self-aware, honest, persistent, and authentic Curious, other-directed, fallible, and humble Creative, oriented to success, self-determined, and perfectionistic

Self-aware, honest, persistent, and authentic

The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as Supervisory Surveillance Technical Maintenance

Supervisory

The nurse is caring for a mother and newborn baby couplet. The mother has a nursing diagnosis of insufficient breast milk but wants to continue to breast feed. The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the baby is gaining weight. What is the most appropriate action by the nurse at this time? Modify the plan of care to follow-up more frequently to assure that the outcome will be met. Refer the couplet to a nutritionist. Contact the lactation consultant and ask if the plan of care needs to be modified. Terminate the plan of care because evaluation reveals that the outcome has been met.

Terminate the plan of care because evaluation reveals that the outcome has been met.

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

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

The clinical nurse manager is evaluating a new nurse who has been employed for 3 months. What type of knowledge does the manager evaluate that is required for competent clinical reasoning? Select all that apply. The nurse can demonstrate basic mathematical problem solving. The nurse understands nursing and medical terminology. The nurse performs skills safely and never makes a mistake. The nurse is committed to the organization's mission and values. The nurse is able to organize and manage time efficiently.

The nurse is committed to the organization's mission and values. The nurse is able to organize and manage time efficiently. The nurse understands nursing and medical terminology.

Which statements describe the common use of problem solving in the nursing process? Select all that apply. The trial-and-error problem-solving method is recommended as a guide for nursing practice. Critical thinking in nursing can be intuitive or logical or a combination of both. The scientific problem-solving method is closely related to the more general problem-solving process (the nursing process) commonly used by health care professionals as they work with clients. Nurse theorists and educators advocate basing clinical judgments on data alone to establish nursing as a science, worthy of the respect of other professions. The trial-and-error problem-solving method is used extensively in the nursing process. Today, nurses acknowledge the positive role of intuitive thinking in clinical decision making.

The scientific problem-solving method is closely related to the more general problem-solving process (the nursing process) commonly used by health care professionals as they work with clients. Today, nurses acknowledge the positive role of intuitive thinking in clinical decision making. Critical thinking in nursing can be intuitive or logical or a combination of both.

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

assessment

The nurse assesses a client's blood pressure, which is 160/90 mm Hg. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure, finding it to be 140/78 mm Hg. Which action has the nurse implemented? Implementing Appraising Planning Evaluating

evaluating

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

intuitive problem identification.

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

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

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified: outcome. intervention. nursing diagnosis. objective data.

outcome

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes? Memorization Reflection Evaluation Assessment

reflection

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

reflective practice.

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: employs communication to meet the client's needs. uses scientific problem solving to meet client problems. uses critical thinking to direct care for the individual client. applies intuition and routine care for clients.

uses critical thinking to direct care for the individual client.