Fundamentals of Nursing Chapter 13 – Flashcards
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After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? A: Initial B: Ongoing C: Discharge D: Strategic
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D: Strategic
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The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? A: Hospital policies B: Standardized care plans C: Orthopedic protocols D: Standards of care
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A: Hospital policies
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The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client's pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but very dry skin. The client declines oral fluids due to nausea, and reports no bowel movements in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan? A: Pain B: Nausea C: Constipation D: Potential for wound infection
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B: Nausea
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The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated outcome/goal? The client will: A: Turn in bed q2h B: Report the importance of applying lotion to skin daily C: Have intact skin during hospitalization D: Use a pressure-reducing mattress
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C: Have intact skin during hospitalization
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The care plan includes a nursing intervention "4/2/11 Measure client's fluid intake and output. F. Jenkins, RN." What element of a proper nursing intervention has been omitted? A: Action verb B: Content C: Time D: None
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C: Time
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Place the following activities of planning in the correct order of their use. A: Establish goals/outcomes B: Write the care plan C: Set priorities D: Choose interventions
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C: Set priorities A: Establish goals/outcomes D: Choose interventions B: Write the care plan
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The nurse recognizes which of the following as a benefit of using a standardized care plan? A: No individualization is needed B: The nurse chooses from a list of interventions C: They are much shorter than the nurse-authored care plans D: They have been approved by accrediting agencies
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B: The nurse chooses from a list of interventions
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Which of the following is likely to occur if the goal statement is poorly written? A: There is no standard against which to compare outcomes B: The nursing diagnoses cannot be prioritized C: Only dependent nursing interventions can be used D: It is difficult to determine which nursing interventions can be delegated
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A: There is no standard against which to compare outcomes
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When written properly, NOC outcomes and indicators: A: Do not require customization B: Address several nursing diagnoses C: Are broad statements of desired end points D: Reflect both the nurse's and the client's values
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D: Reflect both the nurse's and the client's values
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Which of the following principles does the nurse use in selecting interventions for the care plan? A: Actions should address the etiology of the nursing diagnosis B: Always select independent interventions when possible C: There is one best intervention for each goal/outcome D: Interventions should be "doing," not just "monitoring"
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A: Actions should address the etiology of the nursing diagnosis
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The nurse lists the different types of planning that nurses perform, and includes: A: The care plan, interventions, and outcomes B: Initial planning, ongoing planning, and discharge planning C: Interventions, outcomes, and evaluation D: Collaboration with health officials, management of care, and implementation
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B: Initial planning, ongoing planning, and discharge planning
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The nurse is planning the client's care. One of the activities performed by the nurse during this phase is: A: Analyzing data B: Selecting nursing interventions C: Determining the nurse's need for assistance D: Reassessing the client
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B: Selecting nursing interventions
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The nurse is planning care for a pediatric client with a fractured and casted left tibia. The nurse anticipates an appropriate goal for this client is to ultimately reach what level of mobility after removal of the cast and rehabilition? A: 5 (Not compromised) B: 3 (Moderately Compromised) C: 2 (Substantially Compromised) D: 1 (Severely Compromised)
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A: 5 (Not compromised)
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The student nurse is developing a nursing care plan and performs which of the following during the planning phase? A: Reassesses the client B: Determines the need for assistance C: Selects nursing interventions D: Analyze data
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C: Selects nursing interventions
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"The client will ambulate 20 yards without assistance in 8 weeks." The nurse recognizes this is an example of a: A: Nursing intervention B: Long-term goal C: Short-term goal D: Rationale
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B: Long-term goal
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The nurse chooses nursing interventions from the nursing intervention classification based on: A: The nursing process B: Nursing assessments C: Nursing outcomes classification D: Nursing diagnosis
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D: Nursing diagnosis
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The nurse reviews which level of the Nursing Interventions Classification (NIC) taxonomy for interventions? A: Classes B: Level 3 C: Level 1 D: Level 2
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B: Level 3
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When developing client care plans, the first process the nurse engages in is: A: Establishing client goals B: Selecting nursing interventions C: Writing individualized nursing interventions to be performed D: Setting priorities
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D: Setting priorities
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The nurse has identified the nursing diagnosis of Impaired Physical Mobility related to inflammation of knee joint. A short-term goal could be: A: The client will ambulate will crutches by the end of the week B: The client will ambulate C: The client will verbalize his frustration D: The client will stand without assistance by the end of the month
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A: The client will ambulate will crutches by the end of the week
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When writing a nursing goal and desired outcome, the nurse is aware that goals should: A: Be prioritized B: Be taken from a standardized list C: Have physician input D: Be realistic for the client
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D: Be realistic for the client
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"Client will walk to the end of hallway without assistance by Friday" is an example of: A: Nursing intervention B: Rationale C: Long-term goal D: Short-term goal
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D: Short-term goal
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The nurse ranks the following client diagnoses in what priority (from highest to lowest)? A: Ineffective Airway Clearance related to poor cough effort B: Pain related to surgical incision C: Risk for Constipation related to pain medications and decreased activity D: Risk for infection related to surgical incision
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A: Ineffective Airway Clearance related to poor cough effort B: Pain related to surgical incision D: Risk for infection related to surgical incision C: Risk for Constipation related to pain medications and decreased activity
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When writing a care plan, a nurse may use what model or theory to assist in prioritizing? A: Orem's model B: Roy's model C: The most important disease process that the client is experiencing D: Maslow's hierarchy of needs
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D: Maslow's hierarchy of needs
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Which of the following accurately explain how the nurse chooses a nursing intervention? A: Interventions are nurse-initiated activities only B: Most interventions are part of the nurse's dependent role C: Interventions are chosen to alleviate or reduce the impact of the client's medical diagnosis D: Interventions focus on the etiology of the nursing diagnosis
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D: Interventions focus on the etiology of the nursing diagnosis
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Consider the following nursing diagnosis for a client who is on bed rest. Risk for Impaired Skin Integrity related to bed rest. The nursing interventions are derived from the etiologic portion of the nursing diagnosis, which includes: A: Turn and reposition every 2 hours B: Select high-protein foods at each meal C: Proide a daily bath D: Offer a back rub from time to time
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A: Turn and reposition every 2 hours
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The nurse understands that, in order to individualize client care, decisions are made during the planning phase to: A: Set goals for multiple clients B: Address all of the client's disease processes C: Address problems that need individualized approaches D: Address interventions that can be delegated
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C: Address problems that need individualized approaches
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The nurse uses a standardized care plan to develop an individualized care plan for each client. Match the nursing action to the appropriate holistic care plan approach or rationale: The nurse integrates dependent and independent nursing function. A: Ongoing individualized care planning B: Standardized care plan C: Complete individualized plan of care D: Individualized care plan
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C: Complete individualized plan of care
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The nurse uses a standardized care plan to develop an individualized care plan for each client. Match the nursing action to the appropriate holistic care plan approach or rationale: The nurse updates the care plan on the computer to reflect the current client assessment. A: Ongoing individualized care planning B: Standardized care plan C: Complete individualized plan of care D: Individualized care plan
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A: Ongoing individualized care planning
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The nurse uses a standardized care plan to develop an individualized care plan for each client. Match the nursing action to the appropriate holistic care plan approach or rationale: The nurse utilizes the agency's "Brain Tumor" care plan. A: Ongoing individualized care planning B: Standardized care plan C: Complete individualized plan of care D: Individualized care plan
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B: Standardized care plan
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The nurse uses a standardized care plan to develop an individualized care plan for each client. Match the nursing action to the appropriate holistic care plan approach or rationale: The nurse includes family and client preoperative teaching in the client's care plan. A: Ongoing individualized care planning B: Standardized care plan C: Complete individualized plan of care D: Individualized care plan
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D: Individualized care plan
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Nurses use a standardized care plan as: A: A means to address all of the client's disease processes B: A guide in determining if the client is able to assist with the care planning C: A guide for developing nursing diagnoses D: A guide for developing goals and interventions
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D: A guide for developing goals and interventions
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Assessment of a client who is 2 days after surgery reveals a dressing that is dry and intact, temperature 100.2 degrees F, pulse 90, and respiratory rate of 36. The client requests additional juice or water due to a very dry mouth, and says he is feeling weak and having pain with ambulation. The nurse's highest priority finding that indicates that the plan of care should be changed is: A: Elevated temperature B: Dry mouth C: Pain D: Elevated respiratory rate
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D: Elevated respiratory rate
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When setting priorities for delivering care, the nurse considers which of the following processes first? A: The client's home setting B: The most important disease process that the client is experiencing C: The client's ability to pay D: The client's ethnic background
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B: The most important disease process that the client is experiencing
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The best reason for the development of the nursing outcomes classification (NOC) is that: A: Measuring outcomes makes it easier for clients to reach their goals B: The use of NOC will enable nursing data to be analyzed to help improve nursing practice C: NOC outcomes identify the specific behavior to be measured D: A classification system is helpful in writing care plans
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B: The use of NOC will enable nursing data to be analyzed to help improve nursing practice
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The nurse, when developing a care plan, uses the nursing outcome classification to: A: Put interventions into action B: Set priorities C: Measure desired outcomes and evaluate client progress D: Diagnose a client's problem
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C: Measure desired outcomes and evaluate client progress
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A taxonomy of nursing outcome statements was developed to describe measureable states, behaviors, or perceptions to respond to which part of the nursing process? A: Nursing outcomes B: Nursing interventions C: Nuring assessments D: Nursing goals
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B: Nursing interventions
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The nursing intervention classification (NIC): A: Improves cost effectiveness in planning care B: Isolates community input C: Conflicts with nursing management and therapies D: Standardizes and defines the knowledge base for nursing curricula and practice
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D: Standardizes and defines the knowledge base for nursing curricula and practice
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The nurse, who is caring for a client with a nursing diagnosis of Ineffective Airway Clearance, instructs the postoperative client on turning, coughing, and deep breathing every 2 hours. What is the relationship of nursing interventions to problem status? A: Observation interventions B: Health promotion interventions C: Treatment interventions D: Prevention interventions
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D: Prevention interventions
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The nurse finds the nursing interventions of touch in the Nursing Interventions Classification (NIC) by looking up the: A: Problem list B: Client's specific need C: Medical diagnosis D: Nursing diagnosis
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D: Nursing diagnosis
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Which of the following are appropriate nursing guidelines when prioritizing a client's care? A: The items from client identifies as a priority should always be addressed first B: Resolve all high-priority items before addressing lower-priority items C: Priorities change as the client responds to therapies D: Rank nursing diagnoses by degree of importance E: Priorities may need to be shifted based on available resources
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C: Priorities change as the client responds to therapies D: Rank nursing diagnoses by degree of importance
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In the long-term care setting, it is important for the nurse to: A: Revise care plans to reflect standardized protocols B: Revise care plans to reflect goal achievement C: Carry out dependent nursing actions D: Have an informal care plan
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B: Revise care plans to reflect goal achievement
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Outcomes and goals should not only be compatible with the nurse and client, but also with: A: The family B: Other health care workers assigned to the client's care C: The classification system used D: Facility policy
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B: Other health care workers assigned to the client's care
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The home health care nurse is visiting a client with a nursing diagnosis of Activity Intolerance related to the effects of inflammation secondary to rheumatoid arthritis. While planning care with the client, the nurse will: (select all that apply) A: Perform procedures required by the client B: Identify resources to help the client accomplish tasks that require a great deal of energy C: Prioritize care needs D: Set a desired outcome to demonstrate energy conservation E: Assess the client's ability to take care of herself
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B: Identify resources to help the client accomplish tasks that require a great deal of energy C: Prioritize care needs D: Set a desired outcome to demonstrate energy conservation
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Consider the following nursing diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to inability to feed self. What is an example of a short-term goal for this client? A: The client will acquire competence in managing cookware designed for handicapped clients B: The client will choose one correct menu C: The client will eat 50% of his meals by Friday with the use of modified eating utensils to feed self with minimal assistance D: The client will demonstrate safe preparation techniques
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C: The client will eat 50% of his meals by Friday with the use of modified eating utensils to feed self with minimal assistance
