PrepU Ch. 2 – Flashcards

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? a) Complete b) Time-lapse c) Focused d) General

The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal? a) Within 72 hours of admission, the client's respiratory rate returns to normal and retractions disappear. b) Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. c) By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma. d) Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased.

According to Maslow's hierarchy of needs, which nursing diagnosis has the lowest priority for a client admitted to the intensive care unit with a diagnosis of congestive heart failure? a) Ineffective coping b) Impaired urinary elimination c) Risk for body image disturbance d) Ineffective airway clearance

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. In order to promote the health of the family members, what would be the most important information for the nurse to include? a) Medications used to treat diabetes mellitus b) The cellular metabolism of glucose c) Risk factors and prevention of diabetes mellitus d) The severity of the client's disease

A nurse is explaining the purpose of nursing diagnoses to a client. What would be the most appropriate statement for the nurse to make? a) "Nursing diagnoses are used to bill insurance for nursing care." b) "Nursing diagnoses are necessary to schedule the amount of nursing care required by the client." c) "Nursing diagnoses are used to guide the nurse in selecting appropriate nursing interventions." d) "Nursing diagnoses are necessary to validate the medical diagnosis."

A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." In order to assure the safety of the client, what nursing diagnosis would the nurse address? a) Knowledge deficit related to surgical procedure b) Risk for allergy response related to latex allergy c) Risk for injury related to latex allergy d) Anxiety related to surgical procedure

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse's most appropriate plan of action? a) Revise the plan to include the inclusion of a support group. b) Report the client's inability to learn to the case manager. c) Reassess the appropriateness of the method of instruction. d) Teach the content again utilizing the same method.

The client's expected outcome is "The client will maintain skin integrity by discharge." Which of the following measures is best in evaluating the outcome? a) The client's ability to reposition self in bed. b) Percent intake of a diet high in protein. c) Condition of the skin over bony prominences. d) Pressure-relieving mattress on the bed.

The nurse is caring for a client admitted to the hospital for renal calculi. What is the best action to take first? a) Assess for bladder distention. b) Force fluids by mouth. c) Diet as tolerated. d) Strain urine after each void.

Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes? a) Evaluation b) Assessment c) Planning d) Implementation

Implementation of the plan of care is most successful when: a) the nurse avoids further collecting of data until the evaluation phase. b) the nurse takes on care and decision making for the patient. c) the nurse recognizes documentation will occur during another phase. d) the nurse includes family members and other healthcare professionals.

The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the nursing students indicates further education is required? a) "Nursing interventions must be approved by other members of the health care team." b) "Nursing interventions must be consistent with standards of care and research findings." c) "Nursing interventions must be compatible with other therapies planned for the client." d) "Nursing interventions must be culturally sensitive and individualized for the client."

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem? a) Investigate the circumstances that contributed to client falls b) Reprimand the nursing personnel responsible for the clients when the falls occurred c) Institute a new policy on the prevention of client falls on the unit d) Determine if client falls have increased on other nursing units in the hospital

A client is being admitted from the emergency room with complaints of shortness of breath, wheezing, and coughing. Which of the following would the nurse as an appropriate nursing diagnosis? a) Bronchial pneumonia b) Ineffective airway clearance c) Asthma attack d) Acute dyspnea

Which of the following nursing diagnoses has the highest priority when caring for an older adult client with Alzheimer's disease? a) Risk for injury b) Impaired physical mobility c) Impaired memory d) Self-care deficit

Nursing interventions for the client after prostate surgery include assisting the client to ambulate to the bathroom. The nurse concludes that the client no longer requires assistance. What is the nurse's best action? a) Continue assisting the client to the bathroom to ensure the client's safety. b) Instruct the client's family to assist the client to ambulate to the bathroom. c) Consult with the physical therapist to determine the client's ability. d) Revise the care plan to allow the client to ambulate to the bathroom independently.

A preceptor reviews the client outcomes written by a new nurse. Which outcome is the highest priority for the client with paranoid delusions? a) Within 3 days, client will mingle in the day room without violence. b) Within 2 days, client will perform personal hygiene without reminders. c) Client will verbalize side effects of antipsychotic medications within 24 hours. d) Client will discuss delusions in therapy sessions before discharge.

The nurse is preparing a client with a bowel obstruction for emergency surgery. Of the following interventions, which has the highest priority? a) Inform the client what to expect after the surgery. b) Discuss discharge plans with the client. c) Instruct the client and family in wound care. d) Teach the client about dietary restrictions during recovery.

Which nursing action reflects evaluation? a) The nurse sets an anxiety level of 3 or less with the client. b) The nurse identifies that the client has wound drainage. c) The nurse performs a colostomy irrigation. d) The nurse assesses the client's response to pain medication.

A client has just been taught about lowering cholesterol with diet and exercise. What is the best way to evaluate that the client understands the material? a) Accept silence as client understanding. b) Ask direct questions about the teaching plan. c) Allow the client to discuss personal issues. d) Redirect conversation to the topic.

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? a) Risk b) Actual c) Possible d) Wellness

What nursing organization first legitimized the use of the nursing process? a) American Nurses Association b) State Board of Nursing c) National League for Nursing d) International Council of Nursing

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics? a) Wellness diagnosis b) Possible nursing diagnosis c) Actual nursing diagnosis d) Risk nursing diagnosis

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? a) Plan to decrease the pain medication next time. b) Document the effectiveness of the intervention. c) Instruct the client to use imaging and slow breathing. d) Instruct the client to wait as long as possible to ask for medication.

Which of the following group of terms best defines assessing in the nursing process? a) Design a plan of care, implement nursing interventions b) Problem focused, time lapsed, emergency based c) Nurse focused, establishing nursing goals d) Collection, validation, communication of client data

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client's safety, what is the priority action for the nurse to take? a) Tell the client to report any side effects experienced. b) Assess the client's blood pressure to determine if the medication is indicated. c) Determine the client's reaction to the medication in the past. d) Ask the client to verbalize the purpose of the medication.

A client with diabetes mellitus has been admitted to the hospital in diabetic ketoacidosis. During the admission assessment of the client, the nurse learns that the client is not following the prescribed therapeutic regimen. The client states, "I don't really have diabetes. My doctor overreacts." What is the most appropriate diagnosis for this client's health problem? a) Ineffective health maintenance related to client's denial of illness b) Risk for injury related to client's mismanagement of disease c) Ineffective coping related to client's inability to manage the diabetic regimen d) Risk for unstable blood glucose related to client's reluctance to manage the diabetic regimen

One hour after receiving pain medication, a postoperative client complains of intense pain. What is the nurse's most appropriate first action? a) Discuss the frequency of pain medication administration with the client. b) Assess the client to determine the cause of the pain. c) Assist the client to reposition and splint the incision. d) Consult with the physician for additional pain medication.

When a nurse notices the client is in pain and needs to learn to walk on crutches, which outcome identification is the priority? a) Capillary refill b) Safe walking c) Pain management d) Crutch walking

Which of the following best summarizes the evaluating step of the nursing process? a) The nurse and client identify nursing diagnoses and appropriate interventions. b) The nurse completes a health assessment to establish a database. c) The nurse and client measure achievement of planned outcomes of care. d) The client and family have met health care goals and no longer need care.