Term
| The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply. |
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Definition
The client denies the need for education.
The client is blind. |
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Term
| Which parties are essential for the nurse to include in the implementation of a client's plan of care? |
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Definition
Client, family, and health care provider
To ensure the success of the care plan, the nurse must involve all necessary parties. It is essential that the client be involved in the client's own health care decisions. The client's family provides needed support, and the health care provider is essential to provide medical interventions. The hospital director is not necessary for the implementation of the plan of care. A physical therapist and a surgeon are not necessarily involved in every client's care. |
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Term
| When a nurse documents an intervention involving a one-person assist of a client to the chair, which type of nursing intervention does this represent? |
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Definition
Psychomotor
Psychomotor interventions include activities such as positioning, inserting, and applying. A psychosocial intervention focuses on supporting, exploring, and encouraging. Maintenance and surveillance are monitoring interventions. |
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Term
| Which are cognitive client outcomes? Select all that apply. |
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Definition
-The client lists the side effects of digoxin.
-The client describes how to perform progressive muscle relaxation.
-The client identifies signs and symptoms of hypoglycemia. |
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Term
| A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, “I find it easier to use a wheelchair.” What action by the nurse may have led to failure to meet the outcome? |
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Definition
Developing the plan without client input
Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. There is no indication that the nurse included strategies in the plan of care that did not solve the client's problem. There is no evidence that the care plan needed to be updated or that the nurse failed to do so. Although family support can be important to achieving client outcomes, not every client outcome requires family support. |
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Term
| When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "The client will know how to self-administer prescribed bronchodilators using a nebulizer by 09/09/2020." Why is this outcome inadequate? |
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Definition
The outcome is not observable or measurable.
The verb in this outcome, "know," is not directly measurable or observable. The verb "demonstrate" would be more appropriate. Educating a client on how to use a nebulizer is an independent nursing action. The outcome is not expressed as a nursing intervention and conditions are not likely necessary for this outcome. |
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Term
| The nurse is attending a conference on evidence-based practice. Which statement by the nurse indicates further education is needed? |
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Definition
“I must conduct research to validate the usefulness of my nursing interventions.”
Nursing interventions should be supported by a sound scientific rationale; however, nurses do not need to personally conduct research to establish the rationale for nursing interventions. Nurses can learn about evidence-based practice by reading professional nursing journals, attending nursing workshops, and consulting evidence-based practice resources, such as the Agency for Healthcare Research and Quality. |
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Term
| The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining? |
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Definition
Outcome
Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care, such as an expedited discharge of the client based on the client recovering more quickly due to an intervention. The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Cost-effectiveness is not a type of evaluation identified by the American Nurses Association. |
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Term
| The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? |
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Definition
The client with continuous pulse oximetry who requires pharyngeal suctioning.
The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client’s response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel. |
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Term
| The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome? |
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Definition
The nurse has omitted the time frame.
Outcomes are client-centered, use action verbs, identify measurable performance criteria, and include a time frame as to when the outcome should be achieved. The time frame has been omitted. Defining characteristics are a component of the nursing diagnosis, not a client outcome. Because outcomes are client-centered, they describe what the client will do, not what the nurse will do. |
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Term
| A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed: |
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Definition
Peer review
Peer review is a process by which one nurse evaluates the performance of another to improve professional performance. QSEN has as its goal the preparation of nurses with the knowledge, skills, and attitudes necessary to improve the quality and safety of health care systems. AACN strives to provide safe work environments. HCAHPS measures client satisfaction with health care. |
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Term
| A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement? |
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Definition
Physical changes
Physical changes are related to actual body changes in the infant. Psychomotor outcomes are those that are related to new skill attainment. Cognitive outcomes are related to achieving greater knowledge. Affective outcomes are related to feelings and attitudes. |
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Term
| During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse's appropriate first action? |
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Definition
Go to the client and assess the client's pain.
The nurse's first action should always be to determine the cause of the client's pain in order to determine the correct intervention. After determining the cause, the nurse can plan how to proceed. The other steps would be appropriate, but only after the assessment. |
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Term
| For a client with a self-care deficit, the long-term goal is that the client will be able to dress oneself by the end of the 6-week therapy. For best results, when should the nurse evaluate the client’s progress toward this goal? |
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Definition
As soon as possible
Evaluating the progress of a long-term goal prior to the end date encourages and motivates the client to continue working toward the goal. Waiting until the client is discharged or at the end of the 6 weeks does not provide the client the opportunity to feel a sense of accomplishment and motivation to continue working toward the goal. Only evaluating when the client shows progress may lead to the client becoming discouraged. |
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Term
| What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)? |
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Definition
Nurses do carry out interventions in response to a health care provider's order.
A health care provider-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the health care provider and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding health care providers to implement orders, nurses may request a health care provider to implement an order or question an existing order by the health care provider if the nurse believes it is in the client's best interests. |
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Term
| A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours? |
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Definition
Client is normotensive.
A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for hypertension is to have the blood pressure return to the expected range of between 90/60 and 120/80 mm Hg. The other options do not directly indicate successful control of hypertension. |
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Term
| Which outcome for a client with a new colostomy is written correctly? |
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Definition
The client will demonstrate proper care of the stoma by 3/29/20.
Expected client outcomes must be client-centered, specific, measurable, attainable, realistic, and time-bound. "The client will demonstrate proper care of the stoma by 3/29/20" has all of these characteristics. "Explain to the client the proper care of the stoma by 3/29/20" is a nursing intervention, not an outcome. "The client will know how to care for the stoma by 3/29/20" is not measurable. The client demonstrating a technique is measurable. "The client will be able to care for stoma and cope with psychological loss by 3/29/20" contains two goals in one statement. |
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Term
| The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted? |
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Definition
Quality assurance
Accreditation by the Joint Commission evaluates quality assurance. Quality assurance is an externally driven process, demonstrating nursing excellence by meeting professional standards of care. Quality improvement is an internally driven, continuous process focusing on the processes of client care. Peer review is a process whereby individual nurses improve their professional performance through the evaluation of one staff member by another staff member on the same level of the hierarchy. Magnet status is awarded by the American Nurses Credentialing Center, recognizing health care organizations for their excellence in nursing. |
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Term
| Which statement by a nurse case manager regarding this nurse's role in client care is most accurate? |
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Definition
"I provide indirect care to my clients by coordinating their treatment with other disciplines."
Nurses can provide direct, indirect, and collaborative care for their clients. A case manager directs interventions on behalf of the client away from the client's bedside. The most appropriate response is "I provide indirect care...". The case manager's response about the work being important does not adequately explain the role of the case manager. The case manager's role in facilitating financial reimbursement is critical, but does not address the nurse manager's role in client care. The case manager is still providing client care. |
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Term
| The nurse has assisted the client to ambulate for the first time. After returning the client to bed, what is the nurse’s priority intervention? |
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Definition
Assess the client’s response to the ambulation.
After a nurse has performed an intervention, the next step is to evaluate the effectiveness of the intervention. The nurse should assess the client's response to the ambulation. Informing the client when ambulation is scheduled next, discussing the client's feelings, and documenting the ambulation are important, but not until after the client has been reassessed. |
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Term
| A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? |
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Definition
Individualize the plan to the client.
Standardized plans of care are written by a group of nurses who are experts in a given area of practice (e.g., obstetrics, rehabilitation, orthopedics). The plans are written for a client population with a specific medical diagnosis (e.g., total hip replacement, pressure injury, vaginal delivery, coronary artery bypass surgery). These experts identify the most common nursing diagnoses for this client population and write the goals and interventions usually necessary to resolve the problem. Each time a standardized plan of care is used, it must be individualized for a specific client. The danger of a standardized plan of care lies in the fact that it may not fit a specific client. Nurses must make judgments as to the degree to which standardized plans should be modified or whether they should not be used in individual cases. With a standardized plan of care, the most common nursing diagnoses have already been identified. Rationales are typically not included on clinical plans of care. |
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Term
| The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: |
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Definition
discharge planning.
Discharge planning begins at the time of admission with the nurse teaching the client and family specific skills necessary for self-care behaviors in the home. Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning. Initial planning is done at time of admission based on the nurse’s admission assessment. Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship. |
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Term
| The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change? |
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Definition
unlicensed licensed personnel
The nurse should avoid delegating the dressing change to the unlicensed assistive personnel. The dressing change is within the scope of practice of the registered nurse, licensed practical/vocational nurse, and the senior student in nursing school. |
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Term
| Which of the following best summarizes the evaluation step of the nursing process? |
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Definition
The nurse and client measure achievement of planned outcomes of care.
In evaluation, which is the fifth step of the nursing process, the nurse and client together measure how well the client has achieved the outcomes specified in the plan of care. Establishing a health assessment is the first stage of the nursing process. Identifying nursing diagnosis is the second stage and implementation of care is the fourth stage. When the client no longer needs care, the relationship is terminated. |
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Term
| A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, “I find it easier to use a wheelchair.” What action by the nurse may have led to failure to meet the outcome? |
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Definition
Developing the plan without client input
Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. There is no indication that the nurse included strategies in the plan of care that did not solve the client's problem. There is no evidence that the care plan needed to be updated or that the nurse failed to do so. Although family support can be important to achieving client outcomes, not every client outcome requires family support. |
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Term
| 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? |
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Definition
Revise the care plan to allow the client to ambulate to the bathroom independently.
The intervention of assisting the client to the bathroom is no longer indicated, so the nurse would appropriately revise the care plan to discontinue that intervention. A consult with a physical therapist is not necessary to verify the nurse's independent assessment. If the client is safe to ambulate to the restroom independently, it is not necessary for the family to assist. |
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Term
| The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up? |
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Definition
The nurse encourages the client to participate in all treatment decisions as the center of the health care team.
TJC encourages clients to become active, involved, and informed participants on the health care team. By becoming involved and “speaking up” research shows that clients who take part in decisions about their health care are more likely to have better outcomes. The nurse should never want to prevent client questions. While clients are encouraged to be independent, trusted family members and friends can be an asset to the client’s care. The nurse should investigate the possibility of an error if the client questions the nurse about a medication. |
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Term
| The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse’s plan for educating the client and parent? |
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Definition
The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years.
If the family has experience caring for a child with a seizure disorder, the family would already have some basic knowledge, so the nurse would address the education differently. The client expressing a desire to learn indicates receptiveness to the education. The parents' acceptance of their child's condition indicates that they are ready to begin dealing with the child's condition. The fact that the child has comprehensive insurance coverage is a strength that will make options available to the family, but will not necessarily change the nurse's educational plan. |
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Term
Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
Provide the client with assistance in transferring to the bedside commode.
Retrieve a unit of blood from the blood bank.
Reassess the client's sacrum for redness when doing a bed bath.
Assess an IV site for possible infiltration |
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Definition
| Provide the client with assistance in transferring to the bedside commode. |
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Term
| The nurse has performed multiple evaluations on the hospital unit. What evaluation would the nurse identify as a structure evaluation? |
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Definition
Tracking nurse-client ratios on various shifts
Availability of equipment, layout of physical facilities, nurse-client ratios, administrative support, and maintenance of nursing staff competence are some areas of concern for structure evaluation. Deciding whether a client has met their goals of care is an outcome evaluation. Determining the accuracy of a client's nursing diagnoses and a student's ability are process evaluations. |
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Term
Which statement correctly describes a nurse-initiated intervention?
Nurse-initiated interventions are actions deemed to have a low risk of harm to the client.
Nurse-initiated interventions require a health care provider's order.
Nurse-initiated interventions are derived from the nursing diagnosis.
Nurse-initiated interventions are actions performed to diagnose a medical problem. |
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Definition
Nurse-initiated interventions are derived from the nursing diagnosis.
Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis and do not require a health care provider's order. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client. They are not performed to diagnose any problem, medical or otherwise, but to help prevent or resolve a problem identified in a nursing diagnosis and thereby to achieve the related expected client outcome. |
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Term
| A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed: |
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Definition
Peer review
Peer review is a process by which one nurse evaluates the performance of another to improve professional performance. QSEN has as its goal the preparation of nurses with the knowledge, skills, and attitudes necessary to improve the quality and safety of health care systems. AACN strives to provide safe work environments. HCAHPS measures client satisfaction with health care. |
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Term
| One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated? |
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Definition
throughout the client's hospital admission
It is important to evaluate client outcomes early and frequently. Reserving evaluation for the time of discharge or after discharge is inappropriate, even if the designated time criteria for the outcome specifies "by time of discharge." |
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Term
The nurse is implementing the nursing care plan with a client. Which of the nurse's actions best reflects evaluation?
The nurse assesses the client’s response to pain medication.
The nurse identifies that the client has wound drainage.
The nurse sets an anxiety level of 3 or less with the client.
The nurse performs colostomy irrigation. |
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Definition
The nurse assesses the client’s response to pain medication.
Examples of evaluation include assessing the client’s response to pain medication. The focus of diagnosing is recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as a wound infection. Setting an anxiety rating with the client is an example of planning. Performing colostomy irrigation is an example of implementation. |
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Term
| The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client’s recovery, what would be the nurse’s most appropriate intervention? |
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Definition
Encourage the client to provide as much self-care as possible.
The nurse must encourage the client to provide as much self-care as possible in order to achieve the highest level of independence. Performing all care activities for the client makes the client dependent on the nurse. If the family anticipates and meets all the client's needs, this also hinders the client's recovery. An early discharge is not indicated because the client must be sufficiently recovered. |
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Term
| The nurse is assessing the client’s behavioral response to a nursing intervention. This type of evaluation is known as: |
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Definition
outcome evaluation.
Outcome evaluation, which focuses on the client and the client’s function, is currently receiving a great deal of emphasis. Outcome evaluation determines the extent to which the client’s behavioral response to nursing intervention reflects the desired client goal and outcome criteria. The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Behavior modification is not a type of evaluation but a type of intervention that focuses on helping clients make lifestyle changes to achieve health goals. |
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Term
| A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning? |
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Definition
Ongoing
Ongoing planning is carried out by any nurse who interacts with the client following admission and before discharge, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting. Outcome planning is not a specific type of nursing planning, although it would most likely be performed as part of initial planning. |
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Term
| A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse? |
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Definition
Encourage hourly use of the incentive spirometer.
Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve this problem. Reassessment is needed, but this does not replace the need for interventions. |
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Term
| A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? |
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Definition
Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.
Goals must be client-centered, specific, measurable, attainable, realistic, and timebound. “Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse” has all of these characteristics. “The nurse will help the client ambulate the length of the hallway once a day” is not specific in whether assistance is required, is not timebound, and is not client-centered, in that the nurse is the subject of the sentence, not the client. “Offer to help the client walk the length of the hallway each day” is a nursing intervention, not a client outcome. “The client will become mobile within a 24-hour period” is not specific or measurable. |
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Term
| The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse’s best course of action? |
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Definition
Ask the surgeon to wait until the client has had a chance to talk to the spouse.
It is important to consider the client's wishes, so the nurse should advocate for the client and ask the surgeon to wait until the client has talked to the spouse. Telling the client that the client is responsible for the client's own health care decisions does not respect the client's desire to consult the spouse. The client has not expressed being fearful of the spouse. Informing the surgeon that the nurse will not sign the consent form will not satisfy the client's request. |
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Term
| 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? |
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Definition
“Please tell me your thoughts about treating this diagnosis.”
In the planning stage of the nursing process, the nurse must focus on the client’s interests and preferences, keep an open mind, and include interventions that are supported by research. While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client’s choices must be included in the plan for it to be successful. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care. |
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Term
| The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually has what characteristic? |
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Definition
Does not contain explicit scientific rationales.
In clinical settings, nurses may use rationales to illustrate research findings or support controversial approaches to problems. These rationales are not typically included in the clinical nursing care plan. The process of developing both clinical and instructional nursing care plans would follow similar procedures in addressing the other listed aspects of the nursing care planning process. |
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Term
| A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client? |
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Definition
Asking whether the client feels less anxious 30 minutes after administering the medicine
Evaluation allows the nurse to determine whether the client has met the goal. By analyzing the client’s response to the anxiolytic, the nurse determines the effectiveness of the nursing care. The other actions demonstrate other parts of the nursing process: assessment (collecting data about the client's history with anxiety), diagnosis (assigning the client a new nursing diagnosis based on the client’s controlled anxiety), and planning (devising a plan for the client to practice anti-anxiety exercises at home). |
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Term
| Which is an independent (nurse-initiated) action? |
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Definition
Helping to allay a client’s fears about surgery
An independent (nurse-initiated) action is one that a nurse may initiate and carry out independently, without an order from any other health care provider. Helping the client decrease fear about surgery by answering questions or arranging a meeting with the surgeon is an independent nursing intervention. Interventions that involve executing a health care provider's orders, such as for catheterization and medication administration, are dependent nursing interventions. Meeting with other health care professionals describes collaborative care. |
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Term
| A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? |
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Definition
A client with a high fever receiving intravenous fluids, antibiotics, and oxygen
For delegation, the circumstances must be right. The health condition of the client must be stable. The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse. Delegation of taking vital signs would be appropriate for all of the other client's described. |
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Term
| The nurse and client have written the following outcome measure: “The client will eat at least 80% of each meal offered by 3/2.” When should the nurse collect information to evaluate this outcome? |
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Definition
At the completion of each meal
The nurse should collect data at the completion of each meal to ensure the accuracy of the data and to monitor the client's progress toward meeting the goal so that the nurse can make changes to the plan when the client fails to make sufficient progress or celebrate with the client when the client demonstrates success. Although the final evaluation of goal attainment must occur on or shortly after 3/2, data collection must begin far earlier than that. It would not be appropriate for the client to direct when data collection should occur. |
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Term
| Which characteristic is the most important indicator of high-quality nursing practice? |
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Definition
The nurse considers the individual needs of clients.
The personal, compassionate, caring side of a nurse is the most important indicator of quality nursing care. Considering the individual needs of the clients demonstrates the nurse's belief in the importance of the client. Being organized and efficient, following policies and procedures, and ensuring accurate medication administration are important parts of nursing care but are mainly task oriented. |
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Term
| A nurse is evaluating the plan of care for a client and determines that the achievement of goals is difficult to evaluate. What should the nurse do when evaluating the plan to ensure that the outcomes are achievable? Select all that apply. |
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Definition
Specify time limits in the plan.
Make sure the client's expected behavior is written in observable, measurable terms.
Be certain that the subject is the client or some part of the client.
Be sure that the criteria for appropriate response are clearly specified. |
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