Deck 18: Planning Nursing Care

Question 1

Nursing interventions may be categorized based upon the degree of nursing autonomy.An example of a nurse-initiated intervention is:
1) Providing client teaching
2) Administering medication
3) Ordering a liver CAT scan
4) Referring a client to physical therapy

Answer 1

1
Health teaching is an example of a nurse-initiated intervention.Administering medication is a physician-initiated intervention.Ordering a CAT scan is a physician-initiated intervention.Referring a client to physical therapy is a collaborative intervention.

Question 2

A client is newly diagnosed with diabetes mellitus.The nurse identifies a nursing diagnosis of knowledge deficient related to new diagnosis and treatment needs.The most appropriate outcome statement based upon the established criteria is the following:
1) "Client will perform glucose measurements often."
2) "Client will appear less anxious regarding diagnosis."
3) "Urinary output will reach normal young adult levels."
4) "Client will independently perform subcutaneous insulin injection by 8/31."

Answer 2

4
"Client will independently perform subcutaneous insulin injection by 8/31." is the most appropriate outcome statement.It addresses the nursing diagnosis by identifying a singular outcome the client can realistically achieve,is observable,and provides a time frame."Client will perform glucose measurements often." does not specify a time frame."Client will appear less anxious regarding diagnosis." is not an appropriate outcome statement.There is no specific behavior observable for "will appear." "Urinary output will reach normal young adult levels." is not an appropriate outcome statement.It does not provide a standard against which to measure the client's response to nursing care,and therefore is not measurable.It is also not time-limited.

Question 3

The nurse is involved in requesting a management consultation for personnel-related issues.Which of the following is true regarding the consultation process in which the nurse is involved?
1) The problem area should be totally delegated to the consultant.
2) Consultation is often used when the exact problem remains unclear.
3) The problem area is identified by any member of the health care team.
4) Feelings about the problem should be described to the consultant by the nurse.

Answer 3

2
Consultation is appropriate when the nurse has identified a problem that cannot be solved using personal knowledge,skills,and resources,or when the exact problem remains unclear.A consultant objectively entering a situation can more clearly assess and identify the exact nature of the problem.The whole problem is not turned over to the consultant.The consultant is not there to take over the problem but is there to assist the nurse in resolving it.The person requesting the consult usually identifies the problem area.The nurse should not bias the consultant with subjective and emotional conclusions about the client and problem.

Question 4

Assuming that all of the following are realistic,a long-term goal for a client that is a tailor by trade and has been admitted for eye surgery should include:
1) Returning to sewing
2) Preventing ocular infection
3) Administering eye drops on time in the hospital
4) Performing independent hygienic care in the hospital

Question 5

Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team.The most appropriate of the following intervention statements is:
1) Offer fluids to the client q2h
2) Observe the client's respirations
3) Change the client's dressing daily
4) Irrigate the nasogastric tube q2h with 30 ml normal saline

Question 6

In goal setting,the nurse is aware that the factor that is associated with available client resources and motivation is:
1) Realistic
2) Observable
3) Measurable
4) Client-centered

Question 7

In order that they are clear and easily understood by other members of the health care team,the nurse recognizes that client goals or outcomes should be documented according to specific criterion.Of the following,the outcome statement that best meets the established criteria is:
1) "Client will describe activity restrictions."
2) "Client will verbalize understanding of treatments."
3) "Client will be ambulated in hallway 3 times each day."
4) "Client's respiratory rate will remain within 20 to 24 breaths per minute by 9/24."

Question 8

The nurse recognizes that client goals or outcomes should be documented according to specific criterion in order that they are clear and easily understood by other members of the health care team.Of the following,the outcome statement that best meets the established criteria is the following:
1) "Vital signs will return to within normal levels for a middle aged adult."
2) "Nursing assistant will ambulate the client in the hallway 3 times each day."
3) "Lungs will be clear to auscultation and respiratory rate will be 20/minute."
4) "Output will be at least 100 mL/hour of clear yellow urine within 24 hours."

Question 9

Which one of the following interventions selected by the nurse is classified as Level 2,Domain 2 (Physiological: complex)?
1) Maintaining regular bowel elimination
2) Promoting the health of the entire family
3) Managing severely restricted body movement
4) Restoring tissue integrity to areas damaged by friction

Question 10

Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team.The intervention statement "Nurse will apply warm,wet soaks to the patient's leg while awake" lacks which of the following components?
1) Method
2) Quantity
3) Frequency
4) Performing staff

Question 11

Nursing interventions may be categorized based upon the degree of nursing autonomy.Which of the following nursing interventions is considered as physician- or prescriber-initiated?
1) Taking vital signs
2) Providing support to a family
3) Changing a dressing 2 times each day
4) Measuring intake and output each shift

Question 12

The nurse is working with a client who is being prepared for a diagnostic test this afternoon.The client tells the nurse that she wants to have her hair shampooed.Which of the following is the most appropriate label with regard to prioritizing her request?
1) Low priority
2) An unmet need
3) Intermediate priority
4) A safety and security need

Question 13

In completing an assessment on an assigned client,the nurse obtains important information for planning nursing care.Which of the following client needs should take priority?
1) Difficulty breathing
2) Financial problems
3) A nutritional deficit
4) An impending divorce

Question 14

The nurse writes the following goal for a client who is hypertensive: "Client will maintain a blood pressure within acceptable limits." Which of the following would be the most appropriate outcome criterion?
1) "Client will request pain medication as needed."
2) "Client will experience no headache or dizziness."
3) "Client will identify at least two things that cause stress."
4) "Client will have a 7 AM blood pressure reading less than 140/90."

Question 15

In documentation of nursing care plans,critical pathways differ from traditional nursing care plans in their:
1) Client outcomes
2) Client assessment
3) Nursing interventions
4) Multidisciplinary approach

Question 16

Care plans created by nursing students usually differ from those that are completed by nurses working on client units.An aspect of the plan that is usually included in the student's care plan but not in the client's record is:
1) Client outcomes
2) Nursing diagnoses
3) Scientific rationales
4) Nursing interventions

Question 17

Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team.The most appropriate of the following intervention statements is the following:
1) "Take vital signs."
2) "Refer client to a therapist."
3) "Turn client as needed while in bed."
4) "Apply two 4 × 4 dry gauze dressing pads tid."

Question 18

The client is receiving postural drainage from physical therapy and intermittent breathing treatments from respiratory therapy.Which type of care plan would be the ideal method to document interventions for this client?
1) Nursing Kardex
2) Computerized care plan
3) Critical pathway
4) Standardized care plan

Question 19

The purpose and distinction of a concept map,which a nurse may use when implementing a plan of care,are for:
1) Multidisciplinary communication
2) Quality assurance in the health care facility
3) Provision of a standardized format for client problems
4) Identification of the relationship of client problems and interventions

Question 20

Nursing interventions may be categorized based upon the degree of nursing autonomy.Which of the following nursing interventions is considered as physician- or prescriber-initiated?
1) Teaching a client to administer his or her insulin injection
2) Assisting a new mother with learning the art of breast-feeding
3) Notifying the nutritionist of a client's specific dietary preferences
4) Administering a cleansing enema in preparation for radiological testing

Question 21

The expected outcome that best evaluates the presurgical goal of,"Client will understand purpose of coughing and deep breathing within 4 hours of returning to room" is:
1) Client will demonstrate proper technique for coughing and deep breathing
2) Client will cough and deep breathe every 1 hour while awake without staff prompting
3) Client is capable of restating the purpose of coughing and deep breathing in own words
4) Client's lungs will be free of abnormal breath sounds within 1 hour of being returned to room

Question 22

Which of the following would be the best example of a short-term safety goal for a client who recently experienced abdominal surgery?
1) The client will show no systemic or local signs of infection by time of discharge from hospital.
2) The client will demonstrate an understanding of the proper use of patient-controlled analgesia (PCA).
3) The client will demonstrate effective coughing and deep-breathing techniques within 2 hours of surgery.
4) The client will consistently use the call bell to notify the staff of a need for assistance to the bathroom upon return to the nursing unit.

Question 23

The primary function of a care plan is to provide:
1) The client with continuity of care
2) The staff with written client-centered nursing interventions
3) An established criteria for the evaluation of nursing outcomes
4) An organized means of exchanging information between caregivers

Question 24

Which of the following would be the most appropriate outcome criterion for the goal,"Client's pain will be managed to within an acceptable level within 30 minutes of receiving pain medication."
1) Client will deny presence of any pain or discomfort.
2) Client will rate pain at a level of 3 or less out of a possible 10.
3) Client will demonstrate ability to request pain medication as needed.
4) Client will identify two external factors that decrease presence of pain.

Question 25

Which of the following statements made by a new nursing graduate best reflects an understanding of expected outcomes?
1) "It gives the client something positive to strive towards."
2) "They are statements of how the client's behavior should change."
3) "They are measurable criteria by which I can evaluation whether a goal has been achieved."
4) "They provide the client with suggestions on how to achieve their long and short term goals."

Question 26

Which of the following is the best example of an intermediate prioritized client need for a client diagnosed with risk of injury related to poor skin integrity?
1) Applying adequate clothing to ensure the client's warmth
2) Providing sufficient quantities of an aloe-based skin lotion
3) Helping the client select her favorite foods from the menu form
4) Dressing the client's feet in non-skid soled slippers when ambulating

Question 27

The nurse realizes that goals should be singular in focus primarily because:
1) The nurse will find it difficult to modify the plan of care if the goals are not met.
2) The client may not have the strength to accomplish multiply behavioral changes.
3) The client may have difficulty focusing on more than one behavioral modification at a time.
4) The nurse will find it difficult to identify appropriate interventions to address multiple behaviors.

Question 28

Which of the following statements made by the nurse best reflects an understanding of the client's role in goal setting?
1) "He knows what he needs better than anyone else."
2) "When he sets the goals he is more likely to follow the plan."
3) "He identifies the goals and then together we create the plan of action."
4) "He is best suited to determine the level of effort he is capable of providing."

Question 29

A nurse is caring for a client who experienced short-term memory loss as a result of a head injury.Which of the following statements made by the nurse regarding goal setting requires follow-up by the nurse manager?
1) "The client will certainly need frequent reorientation to the care plan goals."
2) "I will restate the goals I've created for him regularly so as to win his compliance."
3) "I'm not sure that his family will be able to support him with these goals but I will discuss it with them."
4) "He seems very willing to work towards achieving his goals but his condition will certainly create barriers."

Question 30

The nurse is caring for a newly admitted client who is scheduled for diagnostic testing in the morning.Which of the following client needs should take priority?
1) Inventory of clothes and other personal belongings
2) Orientation to the nursing unit and individual room
3) Interview regarding medications currently being taken
4) Assessment of body systems for presurgery checklist

Question 31

When developing appropriate nurse-initiated interventions for a client admitted to an acute care facility for abdominal pain,the nurse must first consider:
1) The institution's policies and procedures
2) The state's defined scope of nursing practice
3) The client's physiological and psychological needs
4) The scientific rationale for the proposed nursing action

Question 32

Which of the following goals concerning client anxiety is the best example of measurability?
1) Client will be less anxious by discharge.
2) Client will appear less anxious by discharge.
3) Client will report anxiety at less than 3 out of 5 by discharge.
4) Client pulse rate and blood pressure will be within normal limits by discharge.

Question 33

Which of the following goals best reflects measurability?
1) Client's emotional state will be stable by time of discharge.
2) Client will experience normal sensations in feet by discharge.
3) Client will report being free of shoulder pain by discharge.
4) Client will have acceptable range of motion in elbow by discharge.

Question 34

Which of the following goals best shows that the nurse understands the concept of a client-centered goal?
1) Client will consume at least 75% of each meal served.
2) ADLs will be completed before breakfast is served.
3) Pain will be managed so as to be rated at 3 or less out of 10.
4) Client will be transported to physical therapy by 9 AM daily.

Question 35

A nurse is caring for a client newly diagnosed with diabetes mellitus.Which of the following statements best reflects an understanding of client-centered goals?
1) "The client's A1C levels will be 7 or below at the first testing date."
2) "The client will experience no blood sugar readings below 60 mg/dL before first follow up visit."
3) "The client will be visited weekly by home health nursing staff beginning 1 week after discharge."
4) "The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit."

Question 36

Which of the following outcomes,made by a nurse planning care for a client recently fitted with a hearing aid,best reflects an understanding of short-term client education goals?
1) Client will properly clean the hearing aid ear piece daily with soap and water.
2) Client will state 3 positive effects of wearing his hearing aid at follow-up appointment.
3) Client will wear hearing aid while awake to help improve his ability to understand instructions.
4) Client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today.

Question 37

Which of the following client-centered goals best rest reflects singular focus?
1) Client will cough and deep breathe every hour while awake.
2) Client will be free of shoulder and elbow pain by discharge.
3) Client will adhere to a low-fat diet and lose 3 pounds in 30 days.
4) Client will ambulate to the bathroom for the purpose of showering daily.

Question 38

The nurse realizes that the primary nursing responsibility regarding a physician-initiated intervention is to:
1) Facilitate the intervention in a timely manner
2) Evaluate the client's response to the intervention
3) Possess the technical skills required to implement the intervention
4) Provide client education regarding the implementation of the intervention