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Terms in this set (54)Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses, a: A. Plan is developed for nursing care. A- (next in the Nursing Process) Planning is a category of nursing behaviors in which: A. The nurse determines the health care needed for the client. C (SMART goals & in agreement of all parties involved) Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client's: A. Physician D A client centered goal is a specific and measurable behavior or response that reflects a client's: B For clients to participate in goal setting, they should be: A. Alert and have some degree of independence. A The nurse writes an expected outcome statement in measurable terms. An example is: A. Client will have less pain. C As goals, outcomes, and interventions are developed, the nurse must: A. Be in charge of all care and planning for the client. B When establishing realistic goals, the nurse: A. Bases the goals on the nurse's personal
knowledge. B To initiate an intervention the nurse must be competent in three areas, which include: A. Knowledge, function, and specific skills A Collaborative interventions are therapies that require: A. Physician and nurse interventions. D Well formulated, client-centered goals should: A.
Meet immediate client needs. D The planning step of the nursing process includes which of the following activities? A. Assessing and diagnosing D The nursing care plan is: A. A written guideline for implementation and evaluation. A After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: A. Encourage client to implement guided imagery when pain begins. D When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: A. Apply a cold pack to the tibia. B When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: A. Length of time the current
treatment has been in place. A After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. A. Constipation C,D,A,B The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? A. A client's family attending a diabetic teaching session. B The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? A. A client who is ambulatory. B A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment A: The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B: When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards A:
The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior D: The nurse who documents on the client's care plan the outcome goal "Anxiety will be relieved within 20 to 40 minutes following administration of lorazepam (Ativan)" is engaged in which step of the nursing process? A. Assessment B: Rationale: The planning step of the nursing process involves formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems. Outcome goals are documented on the client's care plan. Assessment data (option 1) is used to help identify a client's human response, and once a plan is established, the interventions are implemented (option 3) and evaluated (option 4). When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B: Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? C: The nurse assigned to care for a postoperative client has asked an unlicensed assistive person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse must do which of the following? A: The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? C: In developing a plan of care for a client with chronic hypertension,
which nursing activity would be most important? C: Which nurse is demonstrating the assessment phase of the nursing
process? C: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? C: The nurse would place which correctly written nursing diagnostic statement into the client's care plan? B: Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. C & D: Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal. The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight and age. The nurse should take which of the following actions? B: Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)? A: In giving a change-of-shift
report, which type of client information communicated by the nurse is most appropriate? D: Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's level of pain has decreased. The nurse documents the client's response as part of which phase of the nursing process? D: During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?" A. Introduction A: The nurse is most likely to collect timely, specific information by asking which of the following questions? A: The nurse should avoid asking the client which of the following leading questions during a client interview? A. "What medication do you take at home?" B: The nurse needs to validate which of the following statements pertaining to an assigned client? C: Which of the following items of subjective
client data would be documented in the medical record by the nurse? D: A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift? A. Nurse and client agree upon health care goals for the client D: The client reports nausea and constipation. Which of the following would be the priority nursing action? A. Collect a stool sample B: The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following? A. Incomplete
data A: Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis? A. Grimacing B: Which
desired outcome written by the nurse is correctly written and measurable? B: Which of these is a correctly
stated outcome goal written by the nurse? A: The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired/expected outcomes should the nurse include in the care plan? A. Client will be able to turn self by day 3 B: While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment? A. Help client into the chair but more quickly D: The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult? A. Formulate a
nursing diagnosis of impaired gas exchange B: A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, "I'm tired of being sick. I wish I could end it all." What is the most accurate and informative way to record this data in a nursing progress note? A. Client appears to be depressed,
possibly suicidal D: The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team? A. Use Liquid PaperTM to "white out" the resolve diagnosis on the care plan D: Sets with similar termsNursing Fundamentals- Nursing Process20 terms julia_r_tomlin NCLEX QUESTIONS: NURSING PROCESS30 terms angelisab28 NCLEX QUESTIONS: NURSING PROCESS30 terms yvonne_bobbert Other sets by this creatorBeta Blockers8 terms khenyadean Angiotensin Converting Enzyme -ACE Inhibitors7 terms khenyadean Pharmacologic Principles6 terms khenyadean Warfarin/Coumadin! (Anticoagulant)11 terms khenyadean Recommended textbook solutionsPharmacology and the Nursing Process7th EditionJulie S Snyder, Linda Lilley, Shelly Collins 382 solutions
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Which of the following is an example of an expected outcome statement in measurable terms?The nurse writes an expected-outcome statement in measurable terms. An example is: A. Patient will be pain free.
Which of the following is the correct order of the nursing process?The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.
Which nursing concept is defined as an actual or potential problem or response to a problem?The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs.
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