Analyze data and create an individualized nursing diagnosis
The nurse is caring for a client that presents with polydipsia, polyphagia, and polyuria. The clients labs reveal in increased Hgb A1C, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?
• Outcomes can be short- and long-term.
• A plan of care should be comprehensive, including the initial, ongoing, and discharge planning.
• Outcome setting allows for individualization of the plan of care.
When developing a nursing plan of care and associated client outcomes, the nurse recognizes which of the following? Select all that apply.
Evaluation
Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this followup with the client, the nurse is utilizing which step of the nursing process?
Measurable
The nurse caring for a client formulates client outcomes based on the understanding that the outcomes should be which of the following?
During her first attempt to turn the client, she realizes that she really needs assistance and calls the front desk for help. After her shift is over, she wonders if all health care providers are using the appropriate resources when turning this client. The next day, the nurse institutes, as part of the client's plan of care, assistance with turning so that the client gets optimal care without injury to the caregivers.
The nurse is caring for an obese client that needs to be turned every 2 hours. Which nursing action is an example of reflection for action?
teach the client how to administer his own insulin
The nursing student recognizes that the most appropriate intervention for a newly diagnosed diabetic client with a nursing diagnosis of deficient knowledge is to:
Evidence-based practice
The nurse understands that research has demonstrated that a common source of hospital-acquired infections in clients with IV infusions is the hub on the IV tubing. Which Quality and Safety Education for Nurses (QSEN) competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing?
Planning
Which step of the nursing process involves setting long-term goals and short-term expectations?
Planning; implementing
The nurse has measured from the tip of the client's nose to his earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which component of the nursing process has the nurse demonstrated?
create an exercise plan that is realistic and valued
An obese client is in the clinic to be started on a weight loss plan. The client tells the nurse that she loves to eat, her favorite food is hamburgers, and she does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for this client? The client will:
Modify the plan of care and interventions to meet the client's needs
The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and upon evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next?
complete postoperative assessment
A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:
Intuition can be a clinically useful adjunct to logical problem solving
Two nurses have disagreed about the role of intuition in nursing practice, with one nurse characterizing it as "hocus-pocus" and the other nurse advocating it as a superior problem-solving strategy. Which of the following statements best conveys the role of intuition in nurses' problem solving?
Establishing the database
Interpreting and analyzing client data
Establishing priorities
Carrying out the plan of care
Measuring how well the client has achieved desired outcomes
Modifying the plan of care (if indicated)
Place the nursing activities in the order that they would most likely occur when a health care professional uses the nursing process.
Prolonged Immobility related to impaired skin integrity AEB 1-inch diameter open area on right buttocks surrounded by a 1-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected.
Which of the following nursing diagnoses is written incorrectly as a result of the health problem and etiology being reversed?
"It seems like you are having difficulty with your care regimen."
A client with diabetes who has been closely following the prescribed plan of care for over a year is being seen at an outpatient setting. 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?
Family
A client is a poor historian of his past medical history. Whom should the nurse consult about the client's past history?
Reporting
The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action?
Quality by inspection
The nurse manager observes one of the unit nurses failing to was her hands upon entering a client room. Hospital protocol is washing hands before and after entering a client room. The nurse manager knows that this is an example of:
reevaluating experience in light of ideas
In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged?
The nurse assesses the client's response to pain medication
Which nursing action reflects evaluation?
"When did you first notice the rash on your leg?"
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?
clinical pathway
The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is a(n)
The charting focuses on client strengths, problems, or needs
Which statement regarding FOCUS charting is most accurate?
a client who was admitted for shortness of breath and who has been diagnosed with pneumonia
For which of the following clients would a standardized plan of care most likely be appropriate?
Clinical reasoning
A client reports weakness following his administration of insulin. The nurse decides to assess the client's blood sugar and prepare a snack in case the blood sugar is low. What action has the nurse implemented?
Nursing assistant
The nurse is assigned a client who had an uneventful colon resection two days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?
The lower extremities
A client has been diagnosed with PVD. What area of the body should the nurse focus the assessment?
Client will alternate rest periods with exercise throughout the day.
A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem?
The nurse is operating under standing orders for clients with MIs
When caring for a client in the emergency room who has presented with symptoms of a (MI) myocardial infarction, the nurse orders laboratory tests and administers medication to the client before the physician has examined the client. In order for the nurse to be operating within the nurse's scope of practice, what conditions must be present?
Affective outcome
The nurse is collecting data on a client presenting to the medical short-stay unit for a colonoscopy. A client reports to the nurse that he quit smoking six months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome?
Write a narrative note in the designated nursing section
A nurse is documenting care in a source-oriented record. What action by the nurse is most appropriate?
Reversed the health problem and the etiology
Which of the following errors has the nurse made in formulating the following nursing diagnosis: Prolonged Immobility related to impaired skin integrity AEB one-inch diameter open area on right buttocks surrounded by a one-inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected.
"The purpose for the assessment offers guidance for which type and how much data to collect."
The nursing student is learning about the different types of assessments, when each type is used, and exactly how much information should be collected each time. Which of the following statements made by the nursing student indicates an understanding of the different types of assessments?
Charting by exception
A nurse documents hypertension in a woman who is 5 months pregnant and then writes a narrative describing the situation. This type of abnormal status can be seen immediately with narrative easily retrieved in what documentation format?
Develops an individualized plan of nursing care
Which of the following does the nurse incorporate with outcome identification and planning in the nursing process?
• Safely ambulating using a walker.
• Accurately drawing up insulin.
Which expected client outcome is an example of a psychomotor outcome? Select all that apply.
legally treatable by registered nurses
One major requirement of a nursing diagnosis is that it focuses on a problem that is:
• 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.
The clinical nurse educator recognizes that the lecture regarding the Quality and Safety Education for Nurses (QSEN) competency was effective when the participants stated that the following is true about informatics in Nursing practice based on QSEN competency? Select all that apply. (pg 210)
• A nurse counsels a young family who is interested in natural family planning.
• A nurse massages the back of a client while performing a skin assessment.
• A nurse helps a client in hospice fill out a living will form.
• A nurse arranges for physical therapy for a client who had a stroke.
Which examples of nursing actions involve direct care of the client? Select all that apply. (pg 307)
Petition to change the protocol based on the new evidence
The emergency room has a strict protocol regarding IM (intramuscular) injection technique. A nurse working in the emergency room has learned of a new technique to decrease pain with IM injections and would like to use it. What is the most appropriate way for the nurse to implement the technique?
• Continue the plan of care if more time could result in achievement of outcomes.
• Modify the plan of care if difficulty has been encountered with achieving outcomes.
• Terminate the plan of care if outcomes have been achieved.
A client has returned to the clinic for a postoperative visit. The nurse reviews the plan of care and could choose to take which action based on the client's previous responses to the current plan of care? Select all that apply.
• Subjective
• Objective
The nurse identifies which of the following as types of data that are used when performing an assessment? Select all that apply.
a guideline
A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: (pg 290)
• To appraise the client's health status
• To identify any health problems
• To establish a database for nursing interventions
A new graduate nurse states that it does not make sense to have to perform such an extensive assessment on clients when they are not feeling well. Which response by the nurse preceptor is an appropriate explanation for conducting a comprehensive physical assessment on clients? Select all that apply.
The client has a normal temperature and no signs and symptoms of infection
Which of the following outcomes does the nurse recognize as being the most appropriate for the client with a nursing diagnosis of risk for infection and an outcome that the client will maintain a normal temperature and exhibit no signs of infection?
Records are randomly selected to determine whether certain standards of care were met and documented
Which of the following is an example of using medical records for quality assurance purposes?
• Record the client's intake and output.
• Assist the client to the bedside commode.
A busy nurse is working with an unlicensed assistive personnel (UAP). What tasks can the nurse appropriately delegate to the UAP? Mark all that apply.
• A client's strong motivation to learn appropriate health behaviors is an example of a positive factor.
• The nurse should understand which factors are helpful to attaining outcome attainment and manipulate them to achieve goals.
• The nurse will draw on positive factors to deal with other variables in the future.
A nurse is caring for a client in the immediate postoperative period and discovers there are factors that are affecting the attainment of client goals. Which of the following is true of factors that influence client responses and outcome achievement? Select all that apply.
Write a client plan of care
The nurse assigned to care for a client has established client outcomes and outcome criteria. After completing this task, what would the nurse do next?
The client states, "I do not know how to take care of a baby."
The nurse has identified a nursing diagnosis of "Risk for Impaired Parenting" for a client who has recently learned of her pregnancy. What assessment data would be appropriate to lead the nurse to select this diagnosis?
Supervisory intervention
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?
"Client states, 'I don't see the point in trying anymore.'"
How should a nurse best document the assessment findings that have caused her to suspect that a client is depressed following his below-the-knee amputation?
Discuss spirituality with the client
A client has a nursing diagnosis of Possible Spiritual Distress. What is the most appropriate nursing intervention?
Terminate the plan of care as it relates to infection
A client presents to the clinic for a routine postoperative visit. The nurse assesses the site of the incision and determines that the edges of the incision are approximated, sutures have been removed, and there is no redness or edema at the site. The incision appears to be well healed. The nurse reviews the plan of care and notes that one nursing diagnosis is related to potential infection related to impaired skin integrity. The nurse determines that this is no longer an issue for the client. Which change should the nurse make to the plan of care?
Reassuring a client that is anxious about a procedure
What is the best example of person-centered care provided by a Registered Nurse (RN)?
"Please tell me your thoughts about treating this diagnosis."
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?
common language
The nursing diagnosis taxonomy provides nursing with:
Continue the health history with questions focusing on respiratory function
The nurse is conducting a nursing 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?
The nurse should address the concern with the surgeon
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 most appropriate first action?
• The client's health record
• Family members accompanying the client
• Other health care professionals
• The client's support people
The nurse understands that when assessing a client, the primary source of information is the client. However, the nurse identifies that other sources of client information can include which of the following? Select all that apply.
choosing actions that do not solve the problem
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?
Ensure that the client's name appears on all pages
When maintaining medical records for a client, the nurse knows that a medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting?
Coordinate with the case manager to make a safe discharge plan
The mother of a pediatric client being discharged confides to the nurse that her husband is abusive and she is afraid to return home. What is the nurse's most appropriate action?
self-aware, honest, persistent, and authentic
Personal characteristics demonstrate that one has developed critical thinking. Characteristics of critical thinking include:
• Identification of health problems
• Appraisal of health status
• Establishment of a database for interventions
The nurse understands that conducting a physical examination on a client should always include which of the following? Select all that apply.
Assist the client to identify strategies to promote safety in the home
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?
rationale
A nurse is caring for a 30-year-old man status post repair of a left femur fracture. He is currently immobilized and on strict bed rest. The nurse enters the client's room every 2 hours to help him change positions because doing so will help to prevent pressure ulcers. The "help to prevent pressure ulcers" portion of this statement is best described as:
By the end of instruction, client will know how to perform dressing changes
A nurse reviews the client outcomes written by a student nurse. Which outcome requires modification?
Document the effectiveness of the intervention
The nurse has administered pain medication to a client with a fractured femur. One hour later, the client reports relief of pain. What is the nurse's next action?
• Nurse assesses client after sneezing into hand.
• Nurse administers medications to wrong client.
• Nurse delays answering call lights to an abusive client.
• Nurse refuses to provide care to a client with HIV.
Quality assurance programs are important for ensuring quality nursing care. Which of the following situations need to be reported to the nurse manager? Select all that apply.
• The client states, "I have no interest in doing anything."
• The client attempted suicide 1 month ago.
• The client no longer indulges in his usual activities.
A nursing diagnosis of "Complicated Grieving" has been identified for a client whose spouse died 1 year ago. What assessment data would be appropriate evidence to justify this diagnosis? Select all that apply.
Nurse-initiated interventions are derived from the nursing diagnosis
Which statement correctly describes a nurse-initiated intervention?
as soon as possible
For a client with self-care deficit, the long-term goal is that the client will be able to dress himself by the end of the 6-week therapy. For best results, when should the nurse evaluate the client's progress toward this goal?
• Consultations
• Lab reports
• Medical history
• Progress notes
• X-Ray reports
The nurse is caring for an older adult client admitted to the hospital for a respiratory condition. Types of data that the nurse should review before caring for this client include which of the following? Select all that apply.
Assess the client's interactions with her newborn
When planning initial care for a 16-year-old mother and her newborn, the nurse formulates a nursing diagnosis of "Risk for Impaired Attachment." What would be the nurse's most appropriate action to take next?
• S: The nurse handling the transfer describes the client situation to the new nurse.
• B: The nurse gives the background of the client by explaining the client history.
• A: The nurse presents an assessment of the client to the new nurse.
• R: The nurse gives recommendations for future care to the new nurse in charge.
A nurse is using the SBAR technique for hand-off communication when transferring a client. What are examples of the use of this process? Select all that apply.
Quality by opportunity
A nurse just reported to the oncoming shift that she had failed to do an ordered dressing change. She reported to the nurse manager that this was the second time this week she had not had time to do the dressing change. The nurse manager recognized that the nurse normally was very punctual and was known to provide good care for her clients however the unit census had been very high on this particular week. The nurse manager knows that quality care must be provided and reports this occurrence as what type of quality approach?
• thinking "outside the box"
• resisting "easy answers" to client problems
• being open to all points of view
Cognitively skilled nurses are critical thinkers. What are characteristics of a critical thinker? Select all that apply.
• The nurse states that the patient's condition "could be life-threatening."
• After introductions, the nurse states the patient name, room number, and problem.
• The nurse reads back the physician's new orders at the conclusion of the call.
The nurse is using the ISBARR format to report a surgical patient's deteriorating condition to a physician. Which actions would the nurse perform when using this guide? (Select all that apply.)
Ask the client if the heart rate is normal to him
A 19-year-old male college basketball player is being evaluated for injuries after a skiing accident. The nurse determines the client has a pulse of 52. What would be the most appropriate way for the nurse to determine the significance of the client's heart rate?
Process evaluation
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?
Review each preceding step of the nursing process
Which action should the nurse take when client data indicate that the stated goals have not been achieved?
• Ineffective Health Maintenance related to lack of motivation as evidenced by client's statement of disinterest in improving health
• Constipation related to side effects of antidepressants as evidenced by passage of hard, dry stool
Which nursing diagnosis is a correctly written 3-part nursing diagnosis? Select all that apply.
The client is free of falls
The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful?
"The benefit of CBE is less time needed on computer charting."
The nurse is explaining charting by exception (CBE) to a client who is curious about documentation. Which statement by the nurse is most accurate?
Intuitive
A client is admitted to the hospital with an abscess on his leg that will not heal after multiple treatment options as an outpatient. The nurse knows from past experiences that the appearance of this type of wound in clients heavily suggests a resistant bacterial infection and the need for contact isolation and IV antibiotics, so she begins to prepare for this admission. What type of problem solving does this exhibit?
PC: Hyperglycemia related to uncontrolled serum glucose
A client with diabetes mellitus has been admitted to the intensive care unit with a serum glucose reading of 400 mg/dL. Because the care for this client will involve multiple disciplines, which diagnostic statement would be most appropriate for the nurse to select?
Risk for Infection related to knowledge deficit
An older adult client's venous ulcer has become foul-smelling after she began using strips of a sheet to dress the wound when she ran out of sterile dressing supplies. How should the nurse document a nursing diagnosis statement related to this client's circumstances?
Effective decision making
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?
• Nursing assessments focus on the client's responses to health problems.
• The findings from a nursing assessment may contribute to the identification of a medical diagnosis.
• An initial assessment establishes a complete database for problem solving and care planning.
Nurses perform assessments on clients as part of their routine care. Which statements accurately describe the unique focus of these nursing assessments? Select all that apply.
The nurse repositions the client to her left side and updates the plan of care to turn and reposition the client every hour
A 63-year-old client in the ICU with a nursing diagnosis of risk for impaired skin integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to her left side she notices that the client has a non-blanching reddened area over her right trochanter. What would be the most appropriate action for the nurse to take?
Psychomotor
The nurse is caring for a client who has a fractured left femur. He will be discharged home this afternoon. The outcome on the plan of care state "Client will demonstrate appropriate cast care prior to discharge" This is an example of what type of evaluative statement?
• Orient the client and family to the room, including the call light button.
• Ask the client questions regarding personal care needs.
The nurse is caring for a client who does not speak the same language. The unlicensed assistive personnel (UAP) speaks the same language as the client. What parts of communicating with the client could the nurse appropriately delegate to the UAP? Select all that apply.
Medical model
The nursing student is learning how to do a complete assessment by organizing the data into the different body systems. This is an example of which of the following types of assessment?
• when nurses work with clients who are able to participate in their care
• when families are clearly supportive and wish to participate in care
• when clients are totally dependent on the nurse for care
• when families are not supportive and do not wish to participate in care.
Nurses use the nursing process to plan care for clients. In which case is the nursing process applicable? Select all that apply.
• Identify factors contributing to the client's health problem.
• Prioritize the client's health problems with input from the client.
• Validate the identified health problems with the clients.
Which activities does the nurse perform during the diagnosing stage? Select all that apply.
variance
A nurse is taking care of a 66-year-old man post knee surgery. She is following a clinical pathway that guides the care of this client after this specific procedure. He is 2 days postoperative and the clinical pathway states that the nurse should advance his diet. The nurse enters the client's room to discuss this order and finds him vomiting in his wastebasket. A change in client care that deviates from the clinical pathway is called:
condition
One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:
• The unlicensed assistive personnel can verbalize what information is to be reported to the nurse.
• Instructions have been clearly communicated by the nurse to the unlicensed assistive personnel.
• The task is delegated to a person with sufficient knowledge and skill for completing the task.
Which are essential components for delegating nursing care? Select all that apply.
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