Question 1

The nurse decides to use a standardized plan of care to address a client's health problems. Which criterion differentiates this plan of care from other types? Select all that apply.

Accepted Answer

A)A standardized plan of care is preprinted and includes checklists, blank lines, or empty spaces to allow the nurse to individualize goals and nursing interventions. A concept map has various shapes connected with lines and is constructed using different colors.
B)A standardized plan of care is preprinted and includes checklists, blank lines, or empty spaces to allow the nurse to individualize goals and nursing interventions. A concept map has various shapes connected with lines and is constructed using different colors.
C)A standardized plan of care is preprinted and includes checklists, blank lines, or empty spaces to allow the nurse to individualize goals and nursing interventions. A concept map has various shapes connected with lines and is constructed using different colors.
D)A standardized plan of care is preprinted and includes checklists, blank lines, or empty spaces to allow the nurse to individualize goals and nursing interventions. A concept map has various shapes connected with lines and is constructed using different colors.
E)A standardized plan of care is preprinted and includes checklists, blank lines, or empty spaces to allow the nurse to individualize goals and nursing interventions. A concept map has various shapes connected with lines and is constructed using different colors.

Question 2

Which statements accurately reflect the distinction between nursing diagnoses and medical diagnoses? Select all that apply.

Accepted Answer

A)Nursing diagnoses consider physical, psychosocial, and spiritual responses to illnesses or conditions, whereas medical diagnoses are concerned primarily with disease processes. Nursing diagnoses change as the client's response to the illness or situation changes, whereas medical diagnoses remain in place as long as the disease process persists. Both nursing and medical diagnoses involve considering client cues as well as standards and norms. Both consider etiology (e.g., "Viral Pneumonia" and "Disturbed Sleep Pattern related to frequent coughing"). Both nursing and medical diagnoses are not only based on information gathered, respectively, by the nurse and physician directly during their assessments, but often include data from other sources.
B)Nursing diagnoses consider physical, psychosocial, and spiritual responses to illnesses or conditions, whereas medical diagnoses are concerned primarily with disease processes. Nursing diagnoses change as the client's response to the illness or situation changes, whereas medical diagnoses remain in place as long as the disease process persists. Both nursing and medical diagnoses involve considering client cues as well as standards and norms. Both consider etiology (e.g., "Viral Pneumonia" and "Disturbed Sleep Pattern related to frequent coughing"). Both nursing and medical diagnoses are not only based on information gathered, respectively, by the nurse and physician directly during their assessments, but often include data from other sources.
C)Nursing diagnoses consider physical, psychosocial, and spiritual responses to illnesses or conditions, whereas medical diagnoses are concerned primarily with disease processes. Nursing diagnoses change as the client's response to the illness or situation changes, whereas medical diagnoses remain in place as long as the disease process persists. Both nursing and medical diagnoses involve considering client cues as well as standards and norms. Both consider etiology (e.g., "Viral Pneumonia" and "Disturbed Sleep Pattern related to frequent coughing"). Both nursing and medical diagnoses are not only based on information gathered, respectively, by the nurse and physician directly during their assessments, but often include data from other sources.
D)Nursing diagnoses consider physical, psychosocial, and spiritual responses to illnesses or conditions, whereas medical diagnoses are concerned primarily with disease processes. Nursing diagnoses change as the client's response to the illness or situation changes, whereas medical diagnoses remain in place as long as the disease process persists. Both nursing and medical diagnoses involve considering client cues as well as standards and norms. Both consider etiology (e.g., "Viral Pneumonia" and "Disturbed Sleep Pattern related to frequent coughing"). Both nursing and medical diagnoses are not only based on information gathered, respectively, by the nurse and physician directly during their assessments, but often include data from other sources.
E)Nursing diagnoses consider physical, psychosocial, and spiritual responses to illnesses or conditions, whereas medical diagnoses are concerned primarily with disease processes. Nursing diagnoses change as the client's response to the illness or situation changes, whereas medical diagnoses remain in place as long as the disease process persists. Both nursing and medical diagnoses involve considering client cues as well as standards and norms. Both consider etiology (e.g., "Viral Pneumonia" and "Disturbed Sleep Pattern related to frequent coughing"). Both nursing and medical diagnoses are not only based on information gathered, respectively, by the nurse and physician directly during their assessments, but often include data from other sources.

Question 3

A client recovering from knee surgery is being prepared to ambulate for the first time. Prior to getting the client up, what should the nurse do?

Accepted Answer

A)Before implementing activities, the nurse considers the impact on the client. In this case, ambulation is likely to be painful, so the nurse evaluates the need for pain medication prior to the intervention. Most clients are not going to want to get up after surgery, and this intervention is not an option for the client. The nurse explains the need and makes the client as comfortable as possible. Assessing the client's breathing is not relevant to the activity. A wheelchair is not appropriate when getting the client ready to ambulate.
B)Before implementing activities, the nurse considers the impact on the client. In this case, ambulation is likely to be painful, so the nurse evaluates the need for pain medication prior to the intervention. Most clients are not going to want to get up after surgery, and this intervention is not an option for the client. The nurse explains the need and makes the client as comfortable as possible. Assessing the client's breathing is not relevant to the activity. A wheelchair is not appropriate when getting the client ready to ambulate.
C)Before implementing activities, the nurse considers the impact on the client. In this case, ambulation is likely to be painful, so the nurse evaluates the need for pain medication prior to the intervention. Most clients are not going to want to get up after surgery, and this intervention is not an option for the client. The nurse explains the need and makes the client as comfortable as possible. Assessing the client's breathing is not relevant to the activity. A wheelchair is not appropriate when getting the client ready to ambulate.
D)Before implementing activities, the nurse considers the impact on the client. In this case, ambulation is likely to be painful, so the nurse evaluates the need for pain medication prior to the intervention. Most clients are not going to want to get up after surgery, and this intervention is not an option for the client. The nurse explains the need and makes the client as comfortable as possible. Assessing the client's breathing is not relevant to the activity. A wheelchair is not appropriate when getting the client ready to ambulate.

Question 4

The novice nurse is writing his first nursing plan of care. He includes category headings for each phase of the nursing process, includes specific and detailed information related to interventions using complete sentences, considers the client's preferences in the chosen interventions, and incorporates preventive and restorative interventions. He then signs and dates the nursing plan of care. What did the nurse do wrong when creating the plan of care?

Accepted Answer

A)When creating a nursing plan of care, the nurse should use category headings related to the nursing process; use approved abbreviations and key words rather than complete sentences; consider the client's preferences when planning care; and incorporate preventive, health maintenance, and restorative interventions. He should also sign and date the nursing plan of care. He should not use complete sentences to communicate ideas and plans unless facility policy dictates otherwise.
B)When creating a nursing plan of care, the nurse should use category headings related to the nursing process; use approved abbreviations and key words rather than complete sentences; consider the client's preferences when planning care; and incorporate preventive, health maintenance, and restorative interventions. He should also sign and date the nursing plan of care. He should not use complete sentences to communicate ideas and plans unless facility policy dictates otherwise.
C)When creating a nursing plan of care, the nurse should use category headings related to the nursing process; use approved abbreviations and key words rather than complete sentences; consider the client's preferences when planning care; and incorporate preventive, health maintenance, and restorative interventions. He should also sign and date the nursing plan of care. He should not use complete sentences to communicate ideas and plans unless facility policy dictates otherwise.
D)When creating a nursing plan of care, the nurse should use category headings related to the nursing process; use approved abbreviations and key words rather than complete sentences; consider the client's preferences when planning care; and incorporate preventive, health maintenance, and restorative interventions. He should also sign and date the nursing plan of care. He should not use complete sentences to communicate ideas and plans unless facility policy dictates otherwise.

Question 5

A nurse has recently joined an orthopedic unit in the United States that specializes in perioperative care of clients undergoing knee or hip replacement. Which nursing plan of care is this nurse likely to use most often?

Accepted Answer

A)The orthopedic unit has a high volume of clients who are undergoing common surgical procedures. Therefore, this unit would likely use standardized plans that specify nursing care for groups of clients with common needs. Column plans and concept maps are frequently used by novice nurses when more details are needed or to stimulate critical thinking. Clinical pathways are also used for clients with common, predictable health outcomes, but they are more commonly used in Canada, Australia, and the United Kingdom.
B)The orthopedic unit has a high volume of clients who are undergoing common surgical procedures. Therefore, this unit would likely use standardized plans that specify nursing care for groups of clients with common needs. Column plans and concept maps are frequently used by novice nurses when more details are needed or to stimulate critical thinking. Clinical pathways are also used for clients with common, predictable health outcomes, but they are more commonly used in Canada, Australia, and the United Kingdom.
C)The orthopedic unit has a high volume of clients who are undergoing common surgical procedures. Therefore, this unit would likely use standardized plans that specify nursing care for groups of clients with common needs. Column plans and concept maps are frequently used by novice nurses when more details are needed or to stimulate critical thinking. Clinical pathways are also used for clients with common, predictable health outcomes, but they are more commonly used in Canada, Australia, and the United Kingdom.
D)The orthopedic unit has a high volume of clients who are undergoing common surgical procedures. Therefore, this unit would likely use standardized plans that specify nursing care for groups of clients with common needs. Column plans and concept maps are frequently used by novice nurses when more details are needed or to stimulate critical thinking. Clinical pathways are also used for clients with common, predictable health outcomes, but they are more commonly used in Canada, Australia, and the United Kingdom.

Question 6

A construction worker admitted to the unit with a chest injury and broken ribs from a fall from a ladder has nursing diagnoses of "Disturbed Sleep Pattern," "Ineffective Breathing Pattern," and "Risk for Infection." The client states, "I've never been sick a day in my life and am really worried about how I can support my family while I'm out of work." When evaluating the client's plan of care during the shift, the nurse adds the nursing diagnosis "Anxiety" to the plan of care. Which diagnosis would be the priority for nursing interventions?

Accepted Answer

A)Nursing diagnoses of "Ineffective Breathing Pattern," "Disturbed Sleep Pattern," and "Risk for Infection" are diagnoses that need to be considered because of the client's inability to fully expand his lungs because of his rib injury. Of these, "Ineffective Breathing Pattern" would receive the highest priority in the nurse's care planning. Addressing the client's disruption in sleep patterns in order to promote quicker healing and taking measures to minimize his risk for infection are also important, but are lower in priority than addressing his current ineffective breathing. In addition, addressing the client's psychosocial needs-his worry about being unable to support his family while he recuperates-is also an important aspect of holistic nursing care, but again of lesser priority than his ability to breathe effectively.
B)Nursing diagnoses of "Ineffective Breathing Pattern," "Disturbed Sleep Pattern," and "Risk for Infection" are diagnoses that need to be considered because of the client's inability to fully expand his lungs because of his rib injury. Of these, "Ineffective Breathing Pattern" would receive the highest priority in the nurse's care planning. Addressing the client's disruption in sleep patterns in order to promote quicker healing and taking measures to minimize his risk for infection are also important, but are lower in priority than addressing his current ineffective breathing. In addition, addressing the client's psychosocial needs-his worry about being unable to support his family while he recuperates-is also an important aspect of holistic nursing care, but again of lesser priority than his ability to breathe effectively.
C)Nursing diagnoses of "Ineffective Breathing Pattern," "Disturbed Sleep Pattern," and "Risk for Infection" are diagnoses that need to be considered because of the client's inability to fully expand his lungs because of his rib injury. Of these, "Ineffective Breathing Pattern" would receive the highest priority in the nurse's care planning. Addressing the client's disruption in sleep patterns in order to promote quicker healing and taking measures to minimize his risk for infection are also important, but are lower in priority than addressing his current ineffective breathing. In addition, addressing the client's psychosocial needs-his worry about being unable to support his family while he recuperates-is also an important aspect of holistic nursing care, but again of lesser priority than his ability to breathe effectively.
D)Nursing diagnoses of "Ineffective Breathing Pattern," "Disturbed Sleep Pattern," and "Risk for Infection" are diagnoses that need to be considered because of the client's inability to fully expand his lungs because of his rib injury. Of these, "Ineffective Breathing Pattern" would receive the highest priority in the nurse's care planning. Addressing the client's disruption in sleep patterns in order to promote quicker healing and taking measures to minimize his risk for infection are also important, but are lower in priority than addressing his current ineffective breathing. In addition, addressing the client's psychosocial needs-his worry about being unable to support his family while he recuperates-is also an important aspect of holistic nursing care, but again of lesser priority than his ability to breathe effectively.

Question 7

The nursing instructor is evaluating a concept map created by a student for a client's plan of care. Which characteristics on the map indicate that the student created the map appropriately? Select all that apply.

Accepted Answer

A)Approaches to building a concept map include developing a legend for each nursing process phase and one for client information, drawing lines between assessment data and associated nursing diagnoses, and using different colors of paper or Post-It notes to represent the phases of the nursing process. A column entitled "evaluation" is a part of a column nursing care plan. A checklist is a part of a standardized nursing care plan.
B)Approaches to building a concept map include developing a legend for each nursing process phase and one for client information, drawing lines between assessment data and associated nursing diagnoses, and using different colors of paper or Post-It notes to represent the phases of the nursing process. A column entitled "evaluation" is a part of a column nursing care plan. A checklist is a part of a standardized nursing care plan.
C)Approaches to building a concept map include developing a legend for each nursing process phase and one for client information, drawing lines between assessment data and associated nursing diagnoses, and using different colors of paper or Post-It notes to represent the phases of the nursing process. A column entitled "evaluation" is a part of a column nursing care plan. A checklist is a part of a standardized nursing care plan.
D)Approaches to building a concept map include developing a legend for each nursing process phase and one for client information, drawing lines between assessment data and associated nursing diagnoses, and using different colors of paper or Post-It notes to represent the phases of the nursing process. A column entitled "evaluation" is a part of a column nursing care plan. A checklist is a part of a standardized nursing care plan.
E)Approaches to building a concept map include developing a legend for each nursing process phase and one for client information, drawing lines between assessment data and associated nursing diagnoses, and using different colors of paper or Post-It notes to represent the phases of the nursing process. A column entitled "evaluation" is a part of a column nursing care plan. A checklist is a part of a standardized nursing care plan.

Question 8

The nurse is prioritizing care for a client with several problems. List the order in which the nurse should address the client's needs.

Accepted Answer

The nurse's priority should follow the ABCs, or airway, breathing, and circulation. Audible wheezes could indicate an obstruction and should be attended to first. Dyspnea indicates a problem with breathing and should be addressed next. Bleeding could impact circulation and should be addressed third. Pain control should be addressed fourth. Reinforcement of teaching can occur fifth, and helping with menu completion can occur last.

Question 9

A nurse enters a client's room to evaluate the response to IV pain medication administered by request 20 minutes earlier. The nurse finds the client in the same position as when the medication was administered. The client states, "I do not want to move." The nurse asks the client to rate the current level of pain. Which aspects of the nursing process do these action represent? Select all that apply.

Accepted Answer

A)The nurse is engaging simultaneously in an assessment, implementation, and evaluation as she (1)observes the client's behavior and asks about her current pain level (assessment), (2)implements an aspect of care by following up on the prior pain administration (implementation), and (3)evaluates the client's response to the earlier pain administration (evaluation). Phases of the nursing process overlap and are not separate entities.
B)The nurse is engaging simultaneously in an assessment, implementation, and evaluation as she (1)observes the client's behavior and asks about her current pain level (assessment), (2)implements an aspect of care by following up on the prior pain administration (implementation), and (3)evaluates the client's response to the earlier pain administration (evaluation). Phases of the nursing process overlap and are not separate entities.
C)The nurse is engaging simultaneously in an assessment, implementation, and evaluation as she (1)observes the client's behavior and asks about her current pain level (assessment), (2)implements an aspect of care by following up on the prior pain administration (implementation), and (3)evaluates the client's response to the earlier pain administration (evaluation). Phases of the nursing process overlap and are not separate entities.
D)The nurse is engaging simultaneously in an assessment, implementation, and evaluation as she (1)observes the client's behavior and asks about her current pain level (assessment), (2)implements an aspect of care by following up on the prior pain administration (implementation), and (3)evaluates the client's response to the earlier pain administration (evaluation). Phases of the nursing process overlap and are not separate entities.
E)The nurse is engaging simultaneously in an assessment, implementation, and evaluation as she (1)observes the client's behavior and asks about her current pain level (assessment), (2)implements an aspect of care by following up on the prior pain administration (implementation), and (3)evaluates the client's response to the earlier pain administration (evaluation). Phases of the nursing process overlap and are not separate entities.

Question 10

The nurse is selected to participate on a committee to write clinical pathways for a specific set of medical diagnoses. Which are advantages of using this approach when providing client care? Select all that apply.

Accepted Answer

A)Clinical pathways sequence the care that must be given on each day during the projected length of stay for the specific type of condition. They include clinical interventions, time frames for completion, usual expectations of response, and expected outcomes. They are also sometimes called multidisciplinary plans because they include medical treatments to be performed by different types of healthcare providers. Concept maps link nursing diagnoses with specific assessment data. Column nursing care plans provide specific columns for diagnosis, interventions, and evaluation.
B)Clinical pathways sequence the care that must be given on each day during the projected length of stay for the specific type of condition. They include clinical interventions, time frames for completion, usual expectations of response, and expected outcomes. They are also sometimes called multidisciplinary plans because they include medical treatments to be performed by different types of healthcare providers. Concept maps link nursing diagnoses with specific assessment data. Column nursing care plans provide specific columns for diagnosis, interventions, and evaluation.
C)Clinical pathways sequence the care that must be given on each day during the projected length of stay for the specific type of condition. They include clinical interventions, time frames for completion, usual expectations of response, and expected outcomes. They are also sometimes called multidisciplinary plans because they include medical treatments to be performed by different types of healthcare providers. Concept maps link nursing diagnoses with specific assessment data. Column nursing care plans provide specific columns for diagnosis, interventions, and evaluation.
D)Clinical pathways sequence the care that must be given on each day during the projected length of stay for the specific type of condition. They include clinical interventions, time frames for completion, usual expectations of response, and expected outcomes. They are also sometimes called multidisciplinary plans because they include medical treatments to be performed by different types of healthcare providers. Concept maps link nursing diagnoses with specific assessment data. Column nursing care plans provide specific columns for diagnosis, interventions, and evaluation.
E)Clinical pathways sequence the care that must be given on each day during the projected length of stay for the specific type of condition. They include clinical interventions, time frames for completion, usual expectations of response, and expected outcomes. They are also sometimes called multidisciplinary plans because they include medical treatments to be performed by different types of healthcare providers. Concept maps link nursing diagnoses with specific assessment data. Column nursing care plans provide specific columns for diagnosis, interventions, and evaluation.

Question 11

The nurse is prioritizing care activities that are to be completed for a group of clients. From highest to lowest priority, list the order in which the nurse should complete the listed activities.

Accepted Answer

The highest-priority action would be to remove an intravenous access device infusing chemotherapy because this could lead to significant tissue damage. Measuring blood pressure before administering antihypertensive medication is the next priority because this could be a timed intervention. Changing a dressing on an arm wound can occur anytime throughout the shift. Ambulating using a walker to the bathroom can be delegated to unlicensed assistive personnel. Requesting a dietary consult for gluten-free diet can also be done at any time and does not have a specific degree of urgency. Contacting family to bring in shoes can be completed at the end of the shift or delayed to the next shift.

Question 12

The nurse is preparing to triage victims of a train derailment who are being transported to the emergency department. Which victims would need immediate care? Select all that apply.

Accepted Answer

A)Emergent or immediate care is needed for life-threatening issues that require prompt treatment and care. Stabilization of the client's condition is critical. A respiratory rate of 8 and a blood pressure of 78/40 mmHg would be emergent. Urgent or delayed care is for serious health conditions in which a delay of treatment and care would not result in life-threatening situations. Holding a broken arm sitting in a chair and bleeding from superficial facial wounds while talking with family would be urgent. Nonurgent or minor issues do not require prompt care. Many of these clients can ambulate and are stable in their conditions. The client walking with a limp and asking for something to drink would be nonurgent.
B)Emergent or immediate care is needed for life-threatening issues that require prompt treatment and care. Stabilization of the client's condition is critical. A respiratory rate of 8 and a blood pressure of 78/40 mmHg would be emergent. Urgent or delayed care is for serious health conditions in which a delay of treatment and care would not result in life-threatening situations. Holding a broken arm sitting in a chair and bleeding from superficial facial wounds while talking with family would be urgent. Nonurgent or minor issues do not require prompt care. Many of these clients can ambulate and are stable in their conditions. The client walking with a limp and asking for something to drink would be nonurgent.
C)Emergent or immediate care is needed for life-threatening issues that require prompt treatment and care. Stabilization of the client's condition is critical. A respiratory rate of 8 and a blood pressure of 78/40 mmHg would be emergent. Urgent or delayed care is for serious health conditions in which a delay of treatment and care would not result in life-threatening situations. Holding a broken arm sitting in a chair and bleeding from superficial facial wounds while talking with family would be urgent. Nonurgent or minor issues do not require prompt care. Many of these clients can ambulate and are stable in their conditions. The client walking with a limp and asking for something to drink would be nonurgent.
D)Emergent or immediate care is needed for life-threatening issues that require prompt treatment and care. Stabilization of the client's condition is critical. A respiratory rate of 8 and a blood pressure of 78/40 mmHg would be emergent. Urgent or delayed care is for serious health conditions in which a delay of treatment and care would not result in life-threatening situations. Holding a broken arm sitting in a chair and bleeding from superficial facial wounds while talking with family would be urgent. Nonurgent or minor issues do not require prompt care. Many of these clients can ambulate and are stable in their conditions. The client walking with a limp and asking for something to drink would be nonurgent.
E)Emergent or immediate care is needed for life-threatening issues that require prompt treatment and care. Stabilization of the client's condition is critical. A respiratory rate of 8 and a blood pressure of 78/40 mmHg would be emergent. Urgent or delayed care is for serious health conditions in which a delay of treatment and care would not result in life-threatening situations. Holding a broken arm sitting in a chair and bleeding from superficial facial wounds while talking with family would be urgent. Nonurgent or minor issues do not require prompt care. Many of these clients can ambulate and are stable in their conditions. The client walking with a limp and asking for something to drink would be nonurgent.

Question 13

What is one of the primary reasons that it is important for nurses to prioritize care?

Accepted Answer

A)Nurses only have a limited amount of time to perform nursing interventions. By prioritizing care, nurses can ensure that high-priority interventions are completed first, followed by medium-priority and then low-priority interventions as time allows. It will likely not be possible for a nurse to plan how to accomplish all activities within one shift. Nurses often accomplish less and are more stressed if they perform the easiest or fastest interventions first. Nurses should consider client preferences for all interventions regardless of the time the intervention is completed.
B)Nurses only have a limited amount of time to perform nursing interventions. By prioritizing care, nurses can ensure that high-priority interventions are completed first, followed by medium-priority and then low-priority interventions as time allows. It will likely not be possible for a nurse to plan how to accomplish all activities within one shift. Nurses often accomplish less and are more stressed if they perform the easiest or fastest interventions first. Nurses should consider client preferences for all interventions regardless of the time the intervention is completed.
C)Nurses only have a limited amount of time to perform nursing interventions. By prioritizing care, nurses can ensure that high-priority interventions are completed first, followed by medium-priority and then low-priority interventions as time allows. It will likely not be possible for a nurse to plan how to accomplish all activities within one shift. Nurses often accomplish less and are more stressed if they perform the easiest or fastest interventions first. Nurses should consider client preferences for all interventions regardless of the time the intervention is completed.
D)Nurses only have a limited amount of time to perform nursing interventions. By prioritizing care, nurses can ensure that high-priority interventions are completed first, followed by medium-priority and then low-priority interventions as time allows. It will likely not be possible for a nurse to plan how to accomplish all activities within one shift. Nurses often accomplish less and are more stressed if they perform the easiest or fastest interventions first. Nurses should consider client preferences for all interventions regardless of the time the intervention is completed.

Question 14

The nurse is prioritizing care for a client based on nursing diagnoses. If following Maslow's hierarchy of needs, list the order in which the nurse should provide care to the client.

Accepted Answer

High-priority nursing diagnoses should be addressed first. This means that Alteration in Perfusion would be the first priority. Medium-priority diagnoses should be addressed next, in order of the impact on physiologic processes. Diarrhea would be a priority over Self-Care Deficit; however, Self-Care Deficit would be a priority over Anxiety. Low-priority diagnoses would be addressed last, again in order of physiologic impact. Fatigue would be a priority over Deficient Knowledge.

Question 15

After receiving the morning report, the nurse prioritizes care needed by several clients. Which factors should the nurse keep in mind when creating this priority list? Select all that apply.

Accepted Answer

A)Prioritization means more than just making decisions about which interventions to do first, second, or third. Factors that influence prioritization include client condition, safety factors, available time, and client preferences. A change in client status may very well require reevaluating priorities and changing the planned order of interventions. Nurses can be fair in their allocation of time, attention, and skills to ensure client safety. Time priorities are determined by the urgency of completing the interventions for the clients. The nurse should strive to honor the client's wishes as much as possible and complete nursing interventions as needed. The nurse needs to complete priority tasks whether or not the task is enjoyable, so nurse preferences are often set aside when creating a priority list of care needed by clients.
B)Prioritization means more than just making decisions about which interventions to do first, second, or third. Factors that influence prioritization include client condition, safety factors, available time, and client preferences. A change in client status may very well require reevaluating priorities and changing the planned order of interventions. Nurses can be fair in their allocation of time, attention, and skills to ensure client safety. Time priorities are determined by the urgency of completing the interventions for the clients. The nurse should strive to honor the client's wishes as much as possible and complete nursing interventions as needed. The nurse needs to complete priority tasks whether or not the task is enjoyable, so nurse preferences are often set aside when creating a priority list of care needed by clients.
C)Prioritization means more than just making decisions about which interventions to do first, second, or third. Factors that influence prioritization include client condition, safety factors, available time, and client preferences. A change in client status may very well require reevaluating priorities and changing the planned order of interventions. Nurses can be fair in their allocation of time, attention, and skills to ensure client safety. Time priorities are determined by the urgency of completing the interventions for the clients. The nurse should strive to honor the client's wishes as much as possible and complete nursing interventions as needed. The nurse needs to complete priority tasks whether or not the task is enjoyable, so nurse preferences are often set aside when creating a priority list of care needed by clients.
D)Prioritization means more than just making decisions about which interventions to do first, second, or third. Factors that influence prioritization include client condition, safety factors, available time, and client preferences. A change in client status may very well require reevaluating priorities and changing the planned order of interventions. Nurses can be fair in their allocation of time, attention, and skills to ensure client safety. Time priorities are determined by the urgency of completing the interventions for the clients. The nurse should strive to honor the client's wishes as much as possible and complete nursing interventions as needed. The nurse needs to complete priority tasks whether or not the task is enjoyable, so nurse preferences are often set aside when creating a priority list of care needed by clients.
E)Prioritization means more than just making decisions about which interventions to do first, second, or third. Factors that influence prioritization include client condition, safety factors, available time, and client preferences. A change in client status may very well require reevaluating priorities and changing the planned order of interventions. Nurses can be fair in their allocation of time, attention, and skills to ensure client safety. Time priorities are determined by the urgency of completing the interventions for the clients. The nurse should strive to honor the client's wishes as much as possible and complete nursing interventions as needed. The nurse needs to complete priority tasks whether or not the task is enjoyable, so nurse preferences are often set aside when creating a priority list of care needed by clients.

Question 16

The nurse manager is concerned that a staff nurse is having difficulty prioritizing client care needs. Which did the manager observe the nurse perform that caused these concerns? Select all that apply.

Accepted Answer

A)Obtaining assessment data from another nurse can provide insight and give a picture of how a client has been during the previous shift; however, using only this information to set priorities may negatively impact client outcomes. Failing to complete an assessment can cause the nurse to miss important and necessary information when setting priorities. Completing easy tasks before doing important, necessary tasks does not make good, professional common sense. Inappropriate delegation may result in the nurse having to do an intervention over or may even result in harm to the client. Reviewing the medication administration record does not negatively impact prioritization.
B)Obtaining assessment data from another nurse can provide insight and give a picture of how a client has been during the previous shift; however, using only this information to set priorities may negatively impact client outcomes. Failing to complete an assessment can cause the nurse to miss important and necessary information when setting priorities. Completing easy tasks before doing important, necessary tasks does not make good, professional common sense. Inappropriate delegation may result in the nurse having to do an intervention over or may even result in harm to the client. Reviewing the medication administration record does not negatively impact prioritization.
C)Obtaining assessment data from another nurse can provide insight and give a picture of how a client has been during the previous shift; however, using only this information to set priorities may negatively impact client outcomes. Failing to complete an assessment can cause the nurse to miss important and necessary information when setting priorities. Completing easy tasks before doing important, necessary tasks does not make good, professional common sense. Inappropriate delegation may result in the nurse having to do an intervention over or may even result in harm to the client. Reviewing the medication administration record does not negatively impact prioritization.
D)Obtaining assessment data from another nurse can provide insight and give a picture of how a client has been during the previous shift; however, using only this information to set priorities may negatively impact client outcomes. Failing to complete an assessment can cause the nurse to miss important and necessary information when setting priorities. Completing easy tasks before doing important, necessary tasks does not make good, professional common sense. Inappropriate delegation may result in the nurse having to do an intervention over or may even result in harm to the client. Reviewing the medication administration record does not negatively impact prioritization.
E)Obtaining assessment data from another nurse can provide insight and give a picture of how a client has been during the previous shift; however, using only this information to set priorities may negatively impact client outcomes. Failing to complete an assessment can cause the nurse to miss important and necessary information when setting priorities. Completing easy tasks before doing important, necessary tasks does not make good, professional common sense. Inappropriate delegation may result in the nurse having to do an intervention over or may even result in harm to the client. Reviewing the medication administration record does not negatively impact prioritization.

Question 17

The nurse is prioritizing care needed for a group of clients according to urgency. Which care should the nurse identify as being medium priority? Select all that apply.

Accepted Answer

A)Medium-priority interventions are those that would not cause a life-threatening situation if performed later throughout the shift. These interventions include passive range of motion exercises and removing splints for skin care. Instructing on ostomy appliance changes is a low-priority intervention. Administering fresh frozen plasma and endotracheal suctioning would be considered critical interventions because if these interventions were not performed, the client's health status could quickly deteriorate.
B)Medium-priority interventions are those that would not cause a life-threatening situation if performed later throughout the shift. These interventions include passive range of motion exercises and removing splints for skin care. Instructing on ostomy appliance changes is a low-priority intervention. Administering fresh frozen plasma and endotracheal suctioning would be considered critical interventions because if these interventions were not performed, the client's health status could quickly deteriorate.
C)Medium-priority interventions are those that would not cause a life-threatening situation if performed later throughout the shift. These interventions include passive range of motion exercises and removing splints for skin care. Instructing on ostomy appliance changes is a low-priority intervention. Administering fresh frozen plasma and endotracheal suctioning would be considered critical interventions because if these interventions were not performed, the client's health status could quickly deteriorate.
D)Medium-priority interventions are those that would not cause a life-threatening situation if performed later throughout the shift. These interventions include passive range of motion exercises and removing splints for skin care. Instructing on ostomy appliance changes is a low-priority intervention. Administering fresh frozen plasma and endotracheal suctioning would be considered critical interventions because if these interventions were not performed, the client's health status could quickly deteriorate.
E)Medium-priority interventions are those that would not cause a life-threatening situation if performed later throughout the shift. These interventions include passive range of motion exercises and removing splints for skin care. Instructing on ostomy appliance changes is a low-priority intervention. Administering fresh frozen plasma and endotracheal suctioning would be considered critical interventions because if these interventions were not performed, the client's health status could quickly deteriorate.

Question 18

A client who has just been diagnosed with type 2 diabetes mellitus is being instructed by the nurse regarding diet and exercise. Which client statements indicate that further teaching is required? Select all that apply.

Accepted Answer

A)The nurse would revise the plan and add more teaching if the client states that candy is necessary for energy and that no dietary planning is needed as long as the client takes insulin. Testing blood sugars before meals and at bedtime is appropriate understanding by the client. Every client is different, and the client should consult the physician regarding starting an exercise program. Limiting fat in the diet is encouraged for this client.
B)The nurse would revise the plan and add more teaching if the client states that candy is necessary for energy and that no dietary planning is needed as long as the client takes insulin. Testing blood sugars before meals and at bedtime is appropriate understanding by the client. Every client is different, and the client should consult the physician regarding starting an exercise program. Limiting fat in the diet is encouraged for this client.
C)The nurse would revise the plan and add more teaching if the client states that candy is necessary for energy and that no dietary planning is needed as long as the client takes insulin. Testing blood sugars before meals and at bedtime is appropriate understanding by the client. Every client is different, and the client should consult the physician regarding starting an exercise program. Limiting fat in the diet is encouraged for this client.
D)The nurse would revise the plan and add more teaching if the client states that candy is necessary for energy and that no dietary planning is needed as long as the client takes insulin. Testing blood sugars before meals and at bedtime is appropriate understanding by the client. Every client is different, and the client should consult the physician regarding starting an exercise program. Limiting fat in the diet is encouraged for this client.
E)The nurse would revise the plan and add more teaching if the client states that candy is necessary for energy and that no dietary planning is needed as long as the client takes insulin. Testing blood sugars before meals and at bedtime is appropriate understanding by the client. Every client is different, and the client should consult the physician regarding starting an exercise program. Limiting fat in the diet is encouraged for this client.

Question 19

The nurse is creating a four-column plan of care for a client. For which areas should the nurse prepare to document when creating this care plan? Select all that apply.

Accepted Answer

A)The column plan of care uses columns to categorize data for each phase of the nursing process. This type of care plan may include four columns: (a)nursing diagnoses, (b)goals/desired outcomes, (c)nursing interventions, and (d)evaluation. Medications are not listed on the plan of care.
B)The column plan of care uses columns to categorize data for each phase of the nursing process. This type of care plan may include four columns: (a)nursing diagnoses, (b)goals/desired outcomes, (c)nursing interventions, and (d)evaluation. Medications are not listed on the plan of care.
C)The column plan of care uses columns to categorize data for each phase of the nursing process. This type of care plan may include four columns: (a)nursing diagnoses, (b)goals/desired outcomes, (c)nursing interventions, and (d)evaluation. Medications are not listed on the plan of care.
D)The column plan of care uses columns to categorize data for each phase of the nursing process. This type of care plan may include four columns: (a)nursing diagnoses, (b)goals/desired outcomes, (c)nursing interventions, and (d)evaluation. Medications are not listed on the plan of care.
E)The column plan of care uses columns to categorize data for each phase of the nursing process. This type of care plan may include four columns: (a)nursing diagnoses, (b)goals/desired outcomes, (c)nursing interventions, and (d)evaluation. Medications are not listed on the plan of care.

Question 20

The nurse is preparing to provide care to a group of clients. On which specific areas should the nurse focus in order to prioritize the clients' care needs? Select all that apply.

Accepted Answer

A)Setting priorities for nursing care always begins with assessment. Assessment includes making observations and asking questions to gather information necessary to make decisions. Helpful assessment data include knowing which clients have complex care issues, if any clients have particular medication times, and if any clients have safety issues that should be addressed. The number of licensed staff is not as important as knowing the number of unlicensed assistive personnel to whom the nurse can delegate client care activities. The time when attending physicians make rounds is not usually part of the criteria when prioritizing client care needs.
B)Setting priorities for nursing care always begins with assessment. Assessment includes making observations and asking questions to gather information necessary to make decisions. Helpful assessment data include knowing which clients have complex care issues, if any clients have particular medication times, and if any clients have safety issues that should be addressed. The number of licensed staff is not as important as knowing the number of unlicensed assistive personnel to whom the nurse can delegate client care activities. The time when attending physicians make rounds is not usually part of the criteria when prioritizing client care needs.
C)Setting priorities for nursing care always begins with assessment. Assessment includes making observations and asking questions to gather information necessary to make decisions. Helpful assessment data include knowing which clients have complex care issues, if any clients have particular medication times, and if any clients have safety issues that should be addressed. The number of licensed staff is not as important as knowing the number of unlicensed assistive personnel to whom the nurse can delegate client care activities. The time when attending physicians make rounds is not usually part of the criteria when prioritizing client care needs.
D)Setting priorities for nursing care always begins with assessment. Assessment includes making observations and asking questions to gather information necessary to make decisions. Helpful assessment data include knowing which clients have complex care issues, if any clients have particular medication times, and if any clients have safety issues that should be addressed. The number of licensed staff is not as important as knowing the number of unlicensed assistive personnel to whom the nurse can delegate client care activities. The time when attending physicians make rounds is not usually part of the criteria when prioritizing client care needs.
E)Setting priorities for nursing care always begins with assessment. Assessment includes making observations and asking questions to gather information necessary to make decisions. Helpful assessment data include knowing which clients have complex care issues, if any clients have particular medication times, and if any clients have safety issues that should be addressed. The number of licensed staff is not as important as knowing the number of unlicensed assistive personnel to whom the nurse can delegate client care activities. The time when attending physicians make rounds is not usually part of the criteria when prioritizing client care needs.

Quiz 36: Clinical Decision Making