Question 1

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 patient outcomes in terms of measurable goals. This can be compared to the goal statement of the traditional care plan, which sets specific objectives for the patient's care. Choice A refers to the NANDA-I nursing diagnosis classification system, and Choice B and D refer to different phases of the care plan, but do not specifically relate to the outcome classification system.

Question 2

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

Accepted Answer

A,B,C,D

Question 3

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 are used to ensure that the care provided meets minimally accepted standards and to promote efficient use of the nurse's time by standardizing care processes.

Question 4

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 such as grab bars and large handled utensils can help the client to improve their fine motor skills. It will also promote independence in activities of daily living. The other options do not specifically address fine motor skill improvement.

Question 5

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

Standardized care plans are designed for specific patient populations with similar health problems, making them suitable for clients undergoing common procedures like hip replacement. They ensure consistency and comprehensiveness in care.

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

The nurse most likely used a protocol to identify and implement interventions for the premature infant. A protocol is a detailed outline of specific steps or actions to be taken in a specific situation, and it can guide the nurse in providing standardized care. Standardized care plans, standards of care, and policy and procedure manuals may also be used in clinical practice but are less likely to provide specific interventions for a specific patient situation.

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 most likely implemented for this client as they require specific care related to their complications following the diagnostic procedure. An individualized care plan would allow for a tailored approach to meet the client's specific needs and situation.

Question 8

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 exact degree range of upright positioning during feeding times. The other options are either part of the diagnosis (D) or the actual intervention (B and C).

Question 9

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

It is not feasible for the home care nurse to prioritize the transportation of the client to the hospital twice daily as it would be impractical and can cause inconvenience to the client. Therefore, the best approach is to assist the client in finding an alternative plan to achieve the desired health outcomes, which may include seeking the services of a local physiotherapist.

Question 10

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 the patient's condition without directly intervening to change it. Providing ongoing assessment for skin breakdown every shift is an example of an observation intervention, as it involves monitoring the skin's condition to identify any changes or potential problems.

Question 11

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

This intervention is specific, measurable, and includes the use of proper equipment (gait belt) to ensure safety while ambulating. It also includes the frequency and duration of the intervention. The other options are too vague or do not provide sufficient details.

Question 12

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, as the medication was routinely used and therefore already ordered for clients with severe hypotension on the unit. A standing order is a pre-approved set of orders for a specific condition or situation that healthcare providers can follow without needing to consult the provider for each individual patient.

Question 13

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?
(Select all that apply)

Accepted Answer

These documents are important because they help ensure that minimally accepted standards of care are met (B), promoting consistency and safety in patient care. They also help in promoting efficient use of the nurse's time (C) by providing clear guidelines and protocols to follow, which can streamline care processes.

Question 14

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

Accepted Answer

Option A is specific and measurable, stating a clear goal (ambulate without a walker) and a timeframe (by 6 weeks), which aligns with the principles of writing effective outcome statements.

Question 15

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

The appropriate goal statement for fluid volume deficit related to diarrhea would be option D, client will have intake of at least 1000 mL within 24 hours. This goal statement is specific, measurable, achievable, relevant, and time-bound. Option A is not specific enough as it does not provide a measurable criteria, Option B refers to an assessment finding rather than a goal, and Option C is not specific enough as it does not state how much fluids the client needs to consume.

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, including all healthcare professionals involved in the client's care, to ensure comprehensive and coordinated care.

Question 17

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 because it requires a healthcare provider's order to be carried out. Repositioning the client, assisting with transfers, and providing physical assessment can be implemented by the nurse autonomously without the need for orders.

Question 18

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 19

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?
(Select all that apply)

Accepted Answer

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

Question 20

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...

Quiz 13: Planning

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

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