Test 2

Question 1

What name is given to standardized plans of care?

Answer 1

Critical pathway

Question 2

Legally speaking how would the nurse ensure that care was not negligent?

Answer 2

Documenting then nursing actions in the client’s record

Question 3

Which of the following group of terms best describes the nursing process?

Answer 3

Patient- centered, systematic, outcomes-oriented

Question 4

What nursing organization first legitimized the use of the nursing process?

Answer 4

American Nurses Association

Question 5

What is a systematic way to form and shape one’s thinking?

Answer 5

Critical Thinking

Question 6

A client age 50 yrs, reports to a primary care unit with an open wound due to a fall. Which of the following nursing actions represents caring skills?

Answer 6

The nurse cleans the wound and applies a dressing to it,

Question 7

The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill?

Answer 7

Cognitive Skill

Question 8

A nurse has come on day shift and is assessing the client’s intravenous setup. The nurse notes that there is a minibag of the clients’ antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the patient’s medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is three hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which of the following?

Answer 8

Ethical/legal skills

Question 9

Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients?

Answer 9

“Assessment data about the client should be collected continuously.”

Question 10

While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client’s chart. Which of the following actions clearly demonstrates assessing?

Answer 10

The nurse asking if the client is having pain

Question 11

When the nurse inspects a postoperative incision site for infection, which of the following assessments is being performed?

Answer 11

Focused

Question 12

What is the primary purpose of validation as part of assessment?

Answer 12

To plan appropriate nursing care

Question 13

A nurse in the emergency dept is completing an emergency assessment for a teenager just from a crash. Which of the following is objective data?

Answer 13

Unable to palpate femoral pulse in left leg

Question 14

When documenting subjective data, the nurse should do which of the following?

Answer 14

Use the client’s own words placed in quotation marks

Question 15

Which of the following is a correct guideline to follow when composing a nursing diagnosis?

Answer 15

Place defining characteristics after the etiology and link them by the phrase, “as evidenced by”

Question 16

Which of the following provides the nurse with the most reliable basis on which to choose a diagnosis?

Answer 16

A cluster of several significant cues of data that suggest a particular health problem

Question 17

After completing assessments, a nurse uses the data collected to identify appropriate nursing diagnosis for the client. For what are the nursing diagnosis used?

Answer 17

Selecting nursing interventions to meet expected outcomes.

Question 18

A nurse is reviewing the health history and physical assessment findings for a client with obesity problems. Of the following data collected, what data from the health history would be used for the diagnosis for this problem?

Answer 18

I get out of breath when I walk a few steps

Question 19

What is the primary purpose of an incident report?

Answer 19

means of identifying risks

Question 20

A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called?

Answer 20

Nursing care rounds

Question 21

A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that took place several months ago. The client is crying uncontrollably and states that he “cant live with this fear.” Which of the following diagnoses for the client is correctly written?

Answer 21

post-trauma syndrome related to being attacked

Question 22

In the nursing diagnosis, Disturbed Self-Esteem related to presence of large scar over left side of face, what part of then nursing diagnosis is “presence of large scar over left side of face”

Answer 22

Etiology

Question 23

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?

Answer 23

Risk for body image disturbance

Question 24

After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis?

Answer 24

Impaired urinary elimination.

Question 25

Upon evaluation of the client’s plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will do what?

Answer 25

Terminate the plan of care

Question 26

Which of the following outcomes is correctly written?

Answer 26

On discharge, client will be able to list five symptoms of infection

Question 27

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcome. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?

Answer 27

Make recommendations for revising the plan of care

Question 28

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client’s priorities for care using which of the following?

Answer 28

assessment skills

Question 29

Which of the following is a correctly written client goal?

Answer 29

The client will ambulate 10 feet with a walker by October 12

Question 30

A nurse forgets to raise the bed railings of a client who is confused after taking pain medications. The client attempts to get out of the bed, and suffers a minor fall. The nurse asks a colleague who witnessed the fall not to mention it to anyone because the client only had minor bruises. What would be the appropriate action of the colleague?

Answer 30

the colleague should inform the nurse that a full report of the incident needs to be made.

Question 31

A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the client’s discharge needs. This interaction is an example of which professional nursing relationship?

Answer 31

Nurse- health care team

Question 32

A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the following would be correct?

Answer 32

“ineffective airway clearance related to thick mucus”

Question 33

The American Nurses Association recommends adherence to defined principles when delegating care to unlicensed assistive personnel. According to these principles, who is responsible and accountable for the practice?

Answer 33

The registered nurse

Question 34

What is the unique focus of nursing implementation?

Answer 34

Client response to health and illness

Question 35

The nurse is collecting data from a home care client. In addition to information about the client, what is another observation the nurse should make?

Answer 35

Safety of the immediate environment

Question 36

A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse?

Answer 36

The nurse transfers responsibility but is accountable for the outcome.

Question 37

Which is a responsibility of the nurse in the nurse-client-family team relationship?

Answer 37

Educate the family to be informed and assertive consumers of health care

Question 38

Each time the nurse administers an insulin injection to a client with diabetes, she tells the client what she is doing and demonstrates each step of preparing and giving the injection. What is the nurse promoting to the client?

Answer 38

Self-care

Question 39

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?

Answer 39

-Condition of the skin over bony prominences

Question 40

The client’s pulse oximetry reading is 97% on room air 30 mins after removal of a nasal cannula. This is an example of what type of outcome?

Answer 40

Physiologic outcome

Question 41

``` The correct sequence of steps for performance improvement is: 1. Discover a problem 2. Plan a strategy using indicators 3. Implement a change. 4, Assess the change. ```

Answer 41

1,2,3,4

Question 42

The nurse witnessed a more senior nurse make six unsuccessful attempts at starting an intravenous line on a client. The senior nurse persisted, stating, “I refuse to admit defeat.” This resulted in unnecessary pain for the client. How should the first nurse best respond to this colleague’s incompetent practice?

Answer 42

Report the nurse’s practice and have the nurse manager address the matter

Question 43

The nurse is reviewing a client’s chart. When reading the history, physical and physician progress notes, the nurse anticipates finding which of the following?

Answer 43

The physician’s assessment and treatment

Question 44

A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content on foods. What type of outcome is this?

Answer 44

Cognitive

Question 45

A client’s diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the chart should be written as

Answer 45

Avelox (moxifloxacin) 400 mg daily

Question 46

A nurse has access to computerized standardized plans of care. After printing one for a client, what should be done next?

Answer 46

Individualize it to the specific client

Question 47

What role of the nurse is crucial to the prevention of fragmentation of care?

Answer 47

Counselor

Question 48

Which of the following reflects the diagnosis phase?

Answer 48

The nurse identifies that the client does not tolerate activity