Question 1

The nurse is reviewing the Nursing Outcomes Classification (NOC)taxonomy system.To what can the nurse compare this taxonomy?
A)Nursing diagnosis statement
B)Planning portion of the care plan
C)Goal statement of the traditional care plan
D)Implementation phase of the care plan

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)
A)Ineffective coping related to drug abuse as evidenced by drug overdose.
B)The client will identify two healthy coping mechanisms by time of discharge.
C)The client has identified two health coping mechanisms to replace inappropriate drug use.
D)The client will be provided with guidance in identifying healthy coping mechanisms.
E)The client has apologized to his family for drug abuse behaviors.

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?
A)Making sure all clients have the same types of care
B)Ensuring that minimally accepted standards are met
C)Promoting efficient use of the nurse's time
D)Eliminating care disparities among clients
E)Ensuring medication errors do not occur

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?
A)Provide assistance as needed with dressing and grooming.
B)Provide assistive devices and educate client to use grab bar and large handled utensils.
C)Make sure lighting and space are adequate for client.
D)Administer medications to improve muscle tone.

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?
A)Informal nursing care plan
B)Formal nursing care plan
C)Standardized care plan
D)Individualized care plan

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?
A)Standardized care plan
B)Protocol
C)Standards of care
D)Policy and procedure manual

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?
A)Informal nursing care plan
B)Formal nursing care plan
C)Standardized care plan
D)Individualized care plan

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?
A)60 to 90 degrees during feeding times
B)Position in chair
C)Upright in a chair
D)Impaired swallowing

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?
A)Make sure that he or she is able to get to the client's home.
B)Assist the client in finding an alternative plan for the achieving the therapy's outcomes.
C)Tell the client that this therapy will be impossible to receive.
D)Make arrangements to have the client moved to a long-term care facility.

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?
A)Turn and reposition client every 2 hours.
B)Cushion bony prominences with soft foam while in bed.
C)Provide ongoing assessment for skin breakdown every shift.
D)Apply lotion to dry skin twice daily.

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?
A)Assist client with ambulation.
B)Ambulate with client,using a gait belt,twice daily for 15 minutes.
C)Make sure client understands the rationale for using the gait belt.
D)Client will ambulate in hallway twice daily.

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?
A)A STAT order
B)A one-time order
C)A prn order
D)A standing order

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)
A)To make sure all clients have the same type of care
B)To ensure that minimally accepted standards of care are met
C)To promote efficient use of the nurse's time
D)To eliminate care disparities among clients
E)To minimize health care costs

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?
A)Client will ambulate without a walker by 6 weeks.
B)Client will ambulate freely in house.
C)Client will not fall.
D)Client will have freer movement in daily activities.

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?
A)Client will drink more fluids by tomorrow.
B)Client will have good skin turgor.
C)Client will have moist mucous membranes.
D)Client will have intake of at least 1000 mL within 24 hours.

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?
A)The admitting nurse
B)All nurses who work with the client
C)Everybody involved in this client's care
D)The client and the client's support system

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?
A)Repositioning the client every 2 hours
B)Assisting the client with transfers to the bathroom
C)Providing ongoing physical assessment,especially of the incisional sites
D)Administering medications for pain

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?
A)Have suction equipment available at all times.
B)Clear secretions from oral/nasal passageways as needed.
C)Keep client in low-Fowler's position to prevent reflux.
D)Provide frequent assessment for presence of obstructive material in mouth and throat.

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)
A)Congruent with the client's values,beliefs,and culture
B)Are within established standards of care
C)Based on scientific and medical knowledge
D)Achievable with the resources available
E)Must be safe and appropriate for the client's age

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?
A)Help the nurse with documentation of the care plan
B)Require that the nurse use sound judgment and knowledge of the client
C)Match nursing diagnoses to exact interventions
D)Help the nurse choose activities that are individualized to the client

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)

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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)

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

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?

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?

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

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?

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)

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