Question 1

During the process of implementing cares and treatments for a client, the nurse realises there are several entities included in this phase.

Accepted Answer

B, D, E

Question 2

The nurse understands that respect for the dignity of the client is extremely important in providing nursing care. Which of the following is an example of this aspect?

Accepted Answer

Encouraging clients to participate in their own hygienic cares shows respect for their autonomy and allows them to maintain their dignity by promoting independence and self-care. Providing all cares to all clients whenever possible is important, but it is not specifically related to respecting the client's dignity. Telling other staff that the client is demanding may not respect the client's privacy or dignity. Presenting information to the client's family about the client's condition is important for informed consent and understanding of the client's care, but it is not specifically related to respecting the client's dignity.

Question 3

A client is learning how to administer insulin. The nurse makes sure that the client understands how to activate the safety mechanism on the syringe to prevent needlestick injuries. This is an example of which of the guidelines for implementing interventions?

Accepted Answer

The nurse is implementing safe care by ensuring that the client knows how to activate the safety mechanism on the syringe to prevent needlestick injuries.

Question 4

A client is struggling to learn how to care for a new colostomy. The nurse is following the written care plan and has selected to provide written information along with a demonstration on how to accurately measure the stoma for attaching the appliance. Upon entering the room, the client is crying along with the client's spouse. The nurse decides to sit with both of them, offering presence and listening to their fears instead of the planned education. This is an example of which of the following?

Accepted Answer

The nurse is reassessing the client's emotional and psychological needs before proceeding with the planned educational intervention, indicating a reassessment of the client's current state and needs.

Question 5

A nurse is working on a medical unit and assigns an unregulated nursing assistant to take vital signs for several clients. The nursing assistant completes this task and documents them accordingly. One of the clients had a blood pressure reading of 180/110, and it wasn't until the end of the shift that the nurse realised this value. The doctor was notified and orders were received for treatment, but not until much later in the shift. Which of the two responsibilities of delegation did the nurse fail to carry out?

Accepted Answer

The answer of A nurse is working on a medical...

Question 6

The written goal statement in a client's care plan is: Client will have clear lung sounds bilaterally within three days. One of the interventions to meet this goal is that the nurse will teach the client to cough and deep breathe and have the client do this several times every two hours. At the end of the third day, the client's lungs are indeed clear. In order to relate the intervention to the outcome, the nurse should:

Accepted Answer

The answer of The written goal statement in a client's...

Question 7

In the nursing process, the implementation phase consists of:

Accepted Answer

The implementation phase involves carrying out the interventions that were developed during the planning phase of care. This is the stage where the nurse puts the plan into action and provides the necessary interventions to the patient. The interventions might include administering medications, providing wound care, or educating the patient and their family members.

Question 8

The student nurse must accurately perform a sterile dressing change before completing a unit of the course. This student is being evaluated on which of the following?

Accepted Answer

Performing a sterile dressing change requires technical skill, which involves the application of practical methods and procedures to complete a task. Academic skill refers to the ability to learn and understand new concepts, cognitive skill refers to the ability to think critically and problem solve, and interpersonal skill refers to the ability to communicate and interact effectively with others. While some of these skills may be utilized during a dressing change, technical skill is the primary skill being evaluated in this scenario.

Question 9

A nurse has provided routine morning cares to a client, including all the medications and scheduled treatments. The most appropriate action after this is completed is for the nurse to:

Accepted Answer

Documenting all cares in the progress notes is essential for legal and continuity of care purposes. It serves as a record of what was done for the client and can be used by other healthcare professionals who may be involved in the client's care. It is important to document accurately and promptly to ensure accuracy and completeness of the client's healthcare record. While getting supplies organized or reporting to the Nurse Unit Manager may be necessary tasks, documenting the cares should be done first. Moving on to the next assignment without documenting the previous care could lead to errors and inadequate record keeping.

Question 10

A new graduate nurse was working with a nurse mentor during the first three months of employment. On one of the first days working alone, the graduate nurse is assigned to care for a client with a new tracheostomy and must provide teaching to the client as well as the client's spouse. This nurse is not familiar with the teaching aspect. The best action for the nurse is to:

Accepted Answer

The best course of action for the new graduate nurse is to ask the nurse mentor for assistance in teaching the client and their spouse about the new tracheostomy. This will ensure that accurate and appropriate information is provided to the client and their spouse. Reviewing policies and procedures may be helpful, but it may not provide sufficient information on client education. Avoiding the assignment is not a solution, as it does not address the problem of inadequate knowledge about tracheostomy teaching. Relying solely on nursing school education may also not be sufficient, as the new graduate nurse may not have received specific training on tracheostomy care and teaching.

Question 11

A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhoea and vomiting was implemented for a home health client who began with these symptoms five days ago. A goal was that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhoea or vomiting for the past five days. The nurse should:

Accepted Answer

The client's symptoms have been resolved for the past five days, meeting the goal set in the care plan, so the nurse should document that the problem has been resolved and discontinue the care for this specific problem.

Question 12

During the process of implementing cares and treatments for a client, the nurse realises there are several processes included in the phase.

Accepted Answer

The answer of During the process of implementing cares and...

Question 13

A nurse works in an acute psychiatric setting and sees clients as they are admitted for inpatient psychiatric care. Many of the clients exhibit paranoid behaviour. The most important skill this nurse can utilise for these clients is which of the following?

Accepted Answer

Interpersonal skills are crucial when working with clients who exhibit paranoid behavior. These skills help in establishing trust and rapport, which are essential for effective communication and therapeutic relationships in psychiatric care.

Question 14

The goal statement for a client's care plan reads as follows: Client will be able to state two positive aspects of rehab therapy by the end of the week. Which of the following is an appropriately written evaluation statement?

Accepted Answer

The goal was for the client to state two positive aspects of rehab therapy by the end of the week. The evaluation statement indicates that the goal was met and the client was able to state two positive aspects by week's end.

Question 15

The nurse is teaching a client about his medication that must be taken with food in the morning. The client states that he didn't 'like the idea' of swallowing tablets early. The nurse should:

Accepted Answer

The answer of The nurse is teaching a client about...

Question 16

A client had an outcome goal stated as follows: Client will have a decrease in pain level (down to a three) within 45 minutes of receiving oral analgesic. Which statement by the client will the nurse use to evaluate this goal?

Accepted Answer

The correct answer is C because it provides a specific numerical value for the pain level, which directly relates to the goal of decreasing the pain level to a three within 45 minutes of receiving an oral analgesic. This allows the nurse to evaluate the effectiveness of the pain management strategy quantitatively.

Question 17

A nurse is working in a busy research hospital. One of the clients assigned to the nurse's care is to receive a medication that the nurse is not familiar with and is not listed in the drug reference manual. The best action of the nurse is to:

Accepted Answer

As a nurse, it is important to always verify the medication and ensure that it is safe to administer. Given that the medication is not listed in the drug reference manual and the nurse is not familiar with it, the best action would be to call the pharmacy and investigate further before administering the medication. This will ensure patient safety and prevent any potential harm.

Question 18

A nursing student does not understand the difference between evaluation and assessment - both are ongoing and both are areas of data collection. In order to differentiate between the two, the student should remember that:

Accepted Answer

The main difference between evaluation and assessment is how the data collected is used. Assessment is used to gather information about a person's health status or condition at the beginning of the process, while evaluation is used to determine the effectiveness of a treatment or intervention at the end of the process. Both involve ongoing data collection, but the purpose and timing of the data collection is different.

Question 19

The implementing phase of the nursing process includes:

Accepted Answer

The implementing phase involves carrying out the nursing interventions that were identified during the planning phase. Evaluation of those interventions is also a part of this phase. Option B refers to the analysis and evaluation of client data, which is a part of the assessment phase. Option C refers to the validation and clustering of client data, which is also a part of the assessment phase. Option D refers to the assessment and planning phases.

Question 20

The home health nurse must devise a way to administer IV antibiotics to a client who insists on being outside during the infusion. Using creativity and critical thinking, the nurse is able to meet the client's requests. This is an example of which of the following?

Accepted Answer

The answer of The home health nurse must devise a...

Quiz 15: Implementing and Evaluating