Question 1

A nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension.What did the nurse implement in this situation?

Accepted Answer

The nurse implemented a standing order, which is a pre-established order that is in effect until it is discontinued by the prescriber or until a specified end date.

Question 2

The nurse wants to create an intervention to assist a client with ambulation.Which statement is the most appropriate manner for the nurse to write this intervention?

Accepted Answer

Option B provides specific details about the intervention, including the frequency and duration of ambulation, as well as the use of a gait belt for safety. This intervention is more comprehensive and effective than the other options, which are either too vague (A and D) or irrelevant to the actual ambulation activity (C).

Question 3

The nurse is reviewing a client's plan of care.Which statements indicate that this care plan has been completed accurately and appropriately?
Standard Text: Select all that apply.

Accepted Answer

A,B,C,D

Question 4

The nursing staff is reviewing standards of care,standardized care plans,protocols,policies,and procedures for a multi-system health care facility.Why are these documents important to the nursing staff when providing client care?
Standard Text: Select all that apply.

Accepted Answer

The answer of The nursing staff is reviewing standards of...

Question 5

A hospital is implementing the use of the NIC (Nursing Interventions Classification)taxonomy.What purpose will the implementation of this taxonomy serve?

Accepted Answer

The answer of A hospital is implementing the use of...

Question 6

The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted premature infant.Which type of document did the nurse use to find these actions?

Accepted Answer

Protocols are specific plans or guidelines for managing a patient in a particular situation, and they often include actions to prevent complications. Standardized care plans, standards of care, and policy and procedure manuals may provide general guidelines, but they are unlikely to offer specific actions for a particular patient or condition.

Question 7

A client is admitted for complications following a routine diagnostic procedure of the colon.Which type of care plan will most likely be implemented for this client?

Accepted Answer

An individualized care plan would be the most appropriate as it allows for tailored interventions to address the specific complications and needs of the client. An informal care plan would not provide sufficient structure or documentation, while a standardized care plan may not be flexible enough to address unique complications. A formal care plan may be used in conjunction with an individualized plan for documentation and organization purposes.

Question 8

The nurse is caring for a client with Parkinson's disease who desires to improve fine motor skills.Which statement should the nurse identify as an appropriate collaborative intervention for this client?

Accepted Answer

Providing assistive devices and educating the client to use grab bars and large handled utensils can help improve fine motor skills in clients with Parkinson's disease. Providing assistance with dressing and grooming and ensuring adequate lighting and space are important interventions, but they do not directly improve fine motor skills. Administering medications may improve muscle tone but may not necessarily improve fine motor skills.

Question 9

A nurse is caring for a client who has a diagnosis of Impaired skin integrity,related to immobility,secondary to neurologic dysfunction.Which should the nurse identify as an observation intervention?

Accepted Answer

Observation interventions involve monitoring and assessing the client's condition. Providing ongoing assessment for skin breakdown every shift is an observation intervention as it involves regularly checking the skin's condition.

Question 10

A discharge goal for a client is to have improved mobility.Which outcome statement did the nurse write appropriately?

Accepted Answer

The outcome statement "Client will ambulate without a walker by 6 weeks" is specific, measurable, and time-bound, making it an appropriate goal for improved mobility.

Question 11

A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care.What should the nurses use to help plan this client's care?

Accepted Answer

The answer of A client is scheduled for elective hip...

Question 12

The nurse is reviewing the Nursing Outcomes Classification (NOC)taxonomy system.To what can the nurse compare this taxonomy?

Accepted Answer

The Nursing Outcomes Classification (NOC) taxonomy system is a standardized language used to describe and measure patient outcomes in a systematic way. It is used in the goal statement of the traditional care plan to identify and evaluate the patient's progress towards achieving specific outcomes.

Question 13

The nurse is devising a care plan for a client with complex health issues and current acute health problems.Which criteria should the nurse ensure is used when planning interventions for this client?
Standard Text: Select all that apply.

Accepted Answer

The answer of The nurse is devising a care plan...

Question 14

The nurse identifies the diagnosis Risk for aspiration,related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident.Which intervention should the nurse identify as including a rationale?

Accepted Answer

The answer of The nurse identifies the diagnosis Risk for...

Question 15

According to the care plan,a client is to receive chest physiotherapy twice daily.The client lives alone in a rural area,does not drive,and is 40 miles away from a hospital.What should the home care nurse do when setting priorities for this client?

Accepted Answer

As the client cannot travel to the hospital twice a day for the therapy, the nurse should try to find an alternative plan to achieve the therapy's outcomes. This may involve finding a local therapist who can come to the client's home, or providing the client with instructions for performing the therapy themselves with the use of special equipment. It is important to work with the client to find a solution that is feasible and effective. Options such as moving the client to a long-term care facility should only be considered if all other options have been exhausted and are not feasible.

Question 16

A client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash.The admitting nurse will develop the initial plan of care,but who will be involved with the ongoing planning of this client's care?

Accepted Answer

Ongoing planning of a client's care in a rehabilitation setting involves a multidisciplinary team approach, which includes everyone involved in the client's care to ensure comprehensive and coordinated treatment.

Question 17

The nurse identifies for a client the nursing diagnosis "Fluid volume deficit,related to active fluid loss,secondary to diarrhea." What would be and appropriate goal statement for this diagnosis?

Accepted Answer

This is the most appropriate and measurable goal statement for the nursing diagnosis of fluid volume deficit. The goal is specific, measurable, achievable, relevant, and time-bound (SMART). It provides a clear target for the client's fluid intake within a specified timeframe. A and B are not specific enough, and C is not measurable.

Question 18

One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees)during feeding times.What should the nurse identify as the modifier in this intervention?

Accepted Answer

The modifier in this intervention is "60 to 90 degrees during feeding times" as it specifies the degree of upright positioning necessary during meals. The other options are either part of the intervention or the nursing diagnosis and do not modify the intervention.

Question 19

The nurse is reviewing interventions written for a client's plan of care.Which intervention should the nurse recognize as being dependent?

Accepted Answer

Administering medications for pain is a dependent intervention, as it requires a healthcare provider's order to be carried out. Repositioning the client, assisting with transfers, and providing physical assessments are all independent nursing interventions that do not require a provider's order.

Question 20

The nurse being oriented to a new position is reviewing the hospital's standards of care,standardized care plans,protocols,policies,and procedures.For which reasons should the nurse realize that these documents are being used by the nursing staff?

Accepted Answer

These documents help ensure that minimally accepted standards are met and promote efficient use of the nurse's time by providing guidelines and protocols for consistent and effective care.

Quiz 13: Planning