Question 1

Which intervention does the nurse recognize as a collaborative intervention?

Accepted Answer

Collaborative interventions involve the nurse working with other healthcare professionals to provide care, such as physical therapists for crutch walking techniques. Administering medication (B), performing tracheostomy care (C), and straight catheterization (D) are all independent nursing interventions.

Question 2

Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? Select all that apply.

Accepted Answer

State Nurse Practice Acts outline specific requirements and expectations for nursing practice within each state, The Joint Commission sets standards for healthcare organizations, and The Agency for Health Care Research and Quality provides evidence-based practice guidelines. Professional physicians' organizations and the Patient Health Partnership may provide guidance, but they are not recognized standards in the same way as the other options.

Question 3

In which of the following clients has the order of priorities for nursing diagnoses changed? Select all that apply.

Accepted Answer

These clients have nursing diagnoses that are not related to their physical condition, but rather to their psychosocial or cognitive status.

Question 4

Which of the following client outcomes best describes the parameters for achieving the outcome?

Accepted Answer

Choice B provides specific parameters for achieving the outcome of a well-balanced diet, including the number of calories, meals, and snacks. Choices A and C lack specificity, and choice D does not provide actionable steps for achieving pain relief.

Question 5

What common problem is related to outcome identification and planning?

Accepted Answer

Involving the client in the planning process is crucial for identifying relevant and achievable outcomes. Failure to do so can lead to plans that are not aligned with the client's needs, preferences, or capabilities, making it a common problem in outcome identification and planning.

Question 6

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

Accepted Answer

Assessment skills are essential in identifying the client's immediate needs and priorities for care. Nursing books, client records, and supervisor's advice can be helpful resources, but they should not replace the nurse's assessment skills in determining the client's priorities for care.

Question 7

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority?

Accepted Answer

The priority outcome is to address the client's anxiety and provide reassurance and support to alleviate their fears. This will help to ensure that the client is mentally prepared for the surgery and reduce the risk of complications such as increased blood pressure or heart rate during the procedure. Providing preoperative education, preparing the client for surgery, and evaluating the need for antibiotics are all important components of the preoperative process, but they are not the priority in this situation.

Question 8

Which of the following statements accurately describes the impact on nursing of using NIC/NOC standardized languages? Select all that apply.

Accepted Answer

The use of NIC/NOC standardized languages demonstrates the impact that nurses have on the system of health care delivery by providing a standardized and defined knowledge base for nursing curricula and practice. It also enables researchers to examine the effectiveness and cost of nursing care. However, it does not limit the number of appropriate nursing interventions to be selected and does not hinder the teaching of clinical decision making to novice nurses.

Question 9

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a physician-initiated intervention?

Accepted Answer

Administering oxygen is a medical intervention that requires a physician's order. The other options are nursing interventions that can be initiated by the nurse without a physician's order.

Question 10

Which of the following is an example of a well-stated nursing intervention?

Accepted Answer

The well-stated nursing intervention should be specific, measurable, time-oriented, and achievable. Option B is a well-stated nursing intervention as it is specific (offering 100mL water to the client), measurable (every 2 hours), time-oriented (while awake), and achievable (can be given by the nurse). Option A is measurable but lacks the specificity of who will provide the water. Option C relies on the client to initiate the request for water, which may not be effective for clients with cognitive or communication issues. Option D is vague and not measurable.

Question 11

Which of the following is a correctly written client goal?

Accepted Answer

The goal is specific, measurable, achievable, relevant, and time-bound, using the SMART criteria.

Question 12

The nurse formulates the following client outcome: Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7. Which error has the nurse made?

Accepted Answer

The nurse has included multiple client behaviors in the outcome, which makes it difficult to measure and achieve. The client drawing up the morning dose of insulin is one behavior, while identifying four signs and symptoms of hypoglycemia is another. It would be more effective to have separate outcomes for each behavior.

Question 13

Which of the following is not appropriate in writing client-centered measurable outcomes?

Accepted Answer

A flexible time frame is not appropriate in writing client-centered measurable outcomes because outcomes need to have specific and concrete timelines to accurately measure progress and success. All other options (A, C, and D) are important elements to include in client-centered measurable outcomes.

Question 14

While developing the plan of care for a new client on the unit the nurse must identify expected outcomes that are appropriate for the new client. What is a resource for identifying these appropriate outcomes?

Accepted Answer

The Nursing-Sensitive Outcomes Classification (NOC) is a standardized classification system that provides nurses with a comprehensive set of standardized outcomes to use in the plan of care development process. The outcomes are evidence-based, measurable, and have been tested for reliability and validity, making them appropriate for use with a variety of clients across healthcare settings. The other options (CSO, SSNOC, and HHROC) are not recognized standardized outcome classifications.

Question 15

Which of the following is a correctly written client goal? Select all that apply.

Accepted Answer

A) The goal is specific, measurable, and has a timeframe.
C) The goal is specific, measurable, and has a specific timeframe.
E) The goal is specific, measurable, and has a percentage as the target.

Quiz 13: Outcome Identification and Planning