The Nursing Process

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1. When caring for a client, a nurse must determine whether the client has achieved the care plan's goals. The nurse determines goal achievement during which step of the nursing process?

Explanation

RATIONALE: During evaluation, the nurse assesses the client's goal achievement by comparing the actual outcome with the outcome identified during the planning step of the nursing process; if needed, the nurse then revises the care plan. During the planning step, the nurse identifies expected client outcomes, establishes priorities, and develops the care plan. During implementation, she delivers nursing care. During assessment, the nurse collects and analyzes data.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 213.

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The Nursing Process - Quiz

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2. When performing an assessment, the nurse identifies the following signs and symptoms: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis?

Explanation

RATIONALE: This client demonstrates the limitation of physical movement defined as Impaired physical mobility. Health-seeking behavior is a state in which a client in stable health actively seeks ways to alter personal health habits or his environment in order to move toward optimal health. Disturbed sensory perception indicates changes in the characteristics of incoming stimuli. Deficient knowledge exists when the client requires further teaching.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 792.

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3. A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is she performing?

Explanation

RATIONALE: During the assessment step of the nursing process, the nurse obtains the client's health history, measures vital signs, and performs a physical examination to gather data for use in formulating the nursing diagnoses. During the planning step, she designs methods to help resolve client problems and meet client needs. During evaluation, she determines the effectiveness of nursing interventions in achieving client goals. During implementation, the nurse takes actions to meet the client's needs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 163.

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4. During the planning step of the nursing process, the nurse:

Explanation

RATIONALE: During the planning step of the nursing process, the nurse determines care priorities, develops goals of care, and selects appropriate interventions to achieve these goals. The nurse collects and records data during the assessment step of the nursing process. She carries out interventions during the implementation step.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 196.

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5. A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, which nursing diagnosis should be the nurse's priority?

Explanation

RATIONALE: The client's statement reveals a Deficient knowledge related to food restrictions associated with general anesthesia. Fear related to surgery, Risk for impaired skin integrity related to upcoming surgery, and Ineffective coping related to the stress of surgery may be applicable nursing diagnoses but they aren't related to the client's statement.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 650.

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6. Which component of an outcome criterion must the nurse consider when setting goals for a client?

Explanation

RATIONALE: The nurse must consider four major components in writing outcome criteria: the content area, an action verb, a time frame, and criterion modifiers. Including a time frame (a target date for completion of the expected outcome criterion) helps the nurse evaluate the client's progress. A place, a family member, and a focal point aren't components of an outcome criterion.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 195.

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7. While caring for a client who's immobile, a nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?

Explanation

RATIONALE: The information documented in the client's chart reflects the risk for impaired skin integrity. Because the client's skin is intact, the problem is only a potential one, not an actual one, which makes the nursing diagnosis of Impaired skin integrity inappropriate. If constipation were a problem, interventions would focus on diet and activity. If body image disturbance were a problem, interventions would focus on the client's feelings about himself and his disease.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1018.

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8. A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client?

Explanation

RATIONALE: Deficient fluid volume related to nausea and vomiting takes highest priority because vomiting causes loss of fluids and electrolytes. No evidence suggests that the client has a fluid volume excess or ineffective cardiopulmonary tissue perfusion. Although the client does have imbalanced nutrition, this nursing diagnosis isn't a high priority at this time.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 942.

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9. After assessing a client, a nurse formulates relevant nursing diagnoses. Which statement is a complete nursing diagnosis statement?

Explanation

RATIONALE: A complete nursing diagnosis has three parts: the actual or potential health problem using the taxonomy of the North American Nursing Diagnosis Association International (NANDA-I), the etiology, and signs and symptoms essential to the diagnosis. Ineffective airway clearance related to mucus plugs and nonproductive cough meets these requirements. Hyperventilation related to anxiety, Tachycardia, and Shortness of breath related to anxiety don't use the NANDA-I taxonomy.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 277.

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10. When obtaining a client's history, the nurse should:

Explanation

RATIONALE: When obtaining a client's history, the nurse gathers subjective data by asking questions about the client's reason for seeking care, current health status, and other factors, such as past medical, family, psychosocial, and nutritional history. The nurse performs palpation and auscultation during the physical examination and documents medications administered when implementing the care plan.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 440.

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11. When documenting information in a client's medical record, the nurse should:

Explanation

RATIONALE: The end of each entry should include the nurse's signature and title; the signature holds the nurse accountable for the recorded information. Erasing errors in documentation on a legal document such as a client's chart isn't permitted by law. Because a client's medical record is considered a legal document, the nurse should make all entries in ink. The nurse is accountable for the information she records and therefore shouldn't leave any blank lines in which another health care worker could make additions.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 247.

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12. One aspect of implementation related to drug therapy is:

Explanation

RATIONALE: Although documentation isn't a step in the nursing process, the nurse is legally required to document activities related to drug therapy, including the time of administration, the quantity, and the client's reaction. Developing a content outline, establishing outcome criteria, and setting realistic client goals are parts of planning rather than implementation.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 365.

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13. A client with heart failure hasn't slept for the past 3 nights because of dyspnea. Arterial blood gas (ABG) analysis reveals pH, 7.32; PaO2, 79 mm Hg; PaCO2, 50 mm Hg; and HCO3–, 29 mEq/L. Which nursing diagnosis takes highest priority for this client?

Explanation

RATIONALE: These ABG values suggest hypoxia (insufficient oxygen in the blood), which indicates impaired gas exchange. Although the diagnoses of Fatigue, Activity intolerance, and Insomnia also may apply to this client, breathing is the first concern.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 838.

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14. A nurse is changing a client's dressing. Which observation of the wound warrants immediate physician notification?

Explanation

RATIONALE: Yellow, purulent drainage suggests infection; the nurse must report this finding to the physician immediately and obtain a culture as ordered. Approximated wound edges, sutures being in place, and pink granulation tissue represent normal findings for a wound.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1192.

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15. A nurse is revising a client's care plan. During which step of the nursing process does she make such revisions?

Explanation

RATIONALE: During the evaluation step of the nursing process, the nurse determines whether the client has achieved the goals established in the care plan and evaluates the success of the plan. If the client hasn't met or has only partially met a goal, the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions. Implementation involves providing actual nursing care.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 213.

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16. A client is admitted to the health care facility with acute chest pain. When obtaining the client's health history, which question would be most helpful for the nurse to ask?

Explanation

RATIONALE: Subjective data (data from the client) about the chest pain help the nurse determine the specific health problem. For example, asking about the setting in which the pain developed can provide helpful information about its cause. Asking if the client needs anything or if family members have been sick wouldn't elicit information related to a cardiac problem. Asking why the client thinks he had a heart attack presumes a particular diagnosis and asks a "why" question, which is a nontherapeutic communication technique.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 440.

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17. During the planning step of the nursing process, the nurse:

Explanation

RATIONALE: During the planning step of the nursing process, the nurse establishes priorities and short- and long-term goals, projects measurable outcomes, and develops a care plan. The nurse determines the client's goal achievement during the evaluation step, writes statements about the client's health problem during the nursing diagnosis step, and gathers objective data during the assessment step.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 196.

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18. Which client characteristic is an example of noncompliance?

Explanation

RATIONALE: Failure to progress is an example of noncompliance. Undesired drug action indicates adverse drug reaction. Multiple questions indicate a client's lack of knowledge about the drug. Resolved symptoms indicate that drug therapy was successful.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 405.

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19. Which source of information helps a nurse formulate nursing diagnoses for a specific client?

Explanation

RATIONALE: The nurse formulates nursing diagnoses after completing the assessment or data collection step in the nursing process. Analyzing essential assessment data and identifying the specific signs or symptoms and probable cause help the nurse diagnose the client. Research articles provide information related to developing current interventions, but they don't help the nurse formulate nursing diagnoses. The nurse formulates outcome criteria after (not before) nursing diagnoses. Admission criteria may help her formulate the diagnoses but won't do so without essential assessment data.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 183.

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20. A nurse is caring for a client with a diagnosis of Impaired gas exchange. Based upon this nursing diagnosis, which outcome is most appropriate?

Explanation

RATIONALE: If the interventions are effective, the client's breath sounds should return to normal. The client should be able to cough effectively and should be encouraged to increase activity, as tolerated. Fluids should help thin secretions, so fluid intake should be encouraged.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE:Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 838.

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21. The daughter of an alert and oriented elderly client asks what her father's most recent blood glucose level was. The nurse's best response would be to:

Explanation

RATIONALE: HIPAA prevents family members or friends from acquiring health information without consent of the client involved. Whether the test was performed on the nursing unit or others had given the client's daughter this information is irrelevant; the client's test results are still protected health information. The nurse shouldn't ask the client's daughter if she has permission because doing so assumes the daughter is telling the truth.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 256.

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22. A client is hospitalized with Pneumocystis carinii pneumonia. A nurse notes that the client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client?

Explanation

RATIONALE: The goal of care for a client with a nursing diagnosis of Social isolation is to identify at least one way to increase the client's social interaction or to involve him in social activities at least weekly. Reporting adaptation to changes in the client's health status, identifying factors contributing to the client's altered sexual patterns, and giving a demonstration of measures that can increase independence aren't goals that address this nursing diagnosis.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1220.

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23. A nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is for the client to:

Explanation

RATIONALE: Walking from the client's room to the end of the hall and back before discharge is a specific, measurable, attainable, and timed goal. It's also a client-oriented outcome goal. Having the client change his own dressing is incomplete and not as significant. Just walking in the hall isn't measurable. The need for a special diet isn't evident in this case.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 294.

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24. A client is breathing 40 breaths/minute. He is diaphoretic and confused. Which nursing diagnosis should be the priority for the client at this time?

Explanation

RATIONALE: Impaired gas exchange is the priority nursing diagnosis for this client. Insomnia, Anxiety, and Risk for injury due to confusion are also appropriate nursing diagnoses, but they are less important at this time.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 838.

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25. Which intervention is an example of primary prevention?

Explanation

RATIONALE: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 73.

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26. When developing a care plan for an older adult, a nurse should consider which challenges that clients in this age-group face?

Explanation

RATIONALE: Challenges faced in older adulthood include adjusting to retirement, deaths of family members, and decreased physical strength. Challenges faced in young adulthood include selecting a vocation, becoming financially independent, and managing a home. Challenges faced in middle adulthood include developing leisure activities, preparing for retirement, and resolving empty-nest crises.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 291.

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27. A nurse is developing a nursing diagnosis for a client. Which information should she include?

Explanation

RATIONALE: A nursing diagnosis is a written statement describing a client's actual or potential health problem. It includes a specified diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the evaluation step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 183.

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28. A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

Explanation

RATIONALE: Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airway, breathing, and circulation take top priority for any client.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 639.

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29. A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?

Explanation

RATIONALE: The nursing actions described constitute evaluation of the expected outcomes. The findings show that the client has achieved the expected outcomes. Assessment consists of the client's history, physical examination, and laboratory studies. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process in which the nurse puts the care plan into action.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 213.

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30. What is a common goal of discharge planning in all care settings?

Explanation

RATIONALE: A common goal of discharge planning in all settings is providing continuity of care for the client. This action aids the client's transition to a new setting and can shorten facility stays. Providing financial assistance isn't a goal of discharge planning, although the nurse may make referrals to the appropriate department for financial assistance. Rather than preventing the need for follow-up visits, the nurse should encourage the client to return for these visits.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 180.

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31. What is the best way for a nurse to maintain security when using computerized client records?

Explanation

RATIONALE: To maintain security of client information, a nurse should never give her computer access code to anyone. If others use her code, inappropriate accessing of information by others would be traced to her. All authorized health care personnel in a facility have individual access codes. It's never appropriate for a nurse to stay logged in to a computer so that others can use it or share her computer access code with another person.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 255.

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32. The following statement appears on a client's care plan: "Client will ambulate in the hall without assistance within 4 days." This statement is an example of:

Explanation

RATIONALE: A client outcome is a short- or long-term goal based on projected nursing interventions. A nursing diagnosis is a statement about a client's actual or potential problem. Subjective data consist of information the client has relayed to the nurse. A nursing intervention is an action the nurse takes in response to a client's problem.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 292.

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33. A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask:

Explanation

RATIONALE: Asking an open-ended question such as "Can you describe the pain?" encourages the client to describe any and all aspects of the pain in his own words. The other options are likely to elicit less information because they're more specific and would limit the client's response.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 491.

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34. Which type of nursing intervention does the nurse perform when she administers oral care to a client?

Explanation

Oral care is an example of a maintenance nursing intervention. Other examples of maintenance nursing interventions include skin care and hygiene. Psychomotor interventions include positioning the client. Educational nursing interventions include the nurse demonstrating and teaching a skill to the client. Supervisory nursing interventions occur when the nurse supervises other health care providers performing a task.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 196.

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35. When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by:

Explanation

RATIONALE: Pulling the pinna back, up, and out helps straighten an adult's ear canal so the nurse can properly place a tympanic thermometer probe. Pulling the ear pinna back, down, and out straightens a child's ear canal. Pulling the ear pinna only out or back doesn't straighten the ear canal for probe placement.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 487.

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36. A client is placed on a low-sodium (500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective?

Explanation

RATIONALE: The client's choice of a baked potato with broiled chicken indicates effective nutrition teaching because potatoes and chicken are relatively low in sodium. Ham, sardines, and bouillon are extremely high in sodium and shouldn't be included in a low-sodium diet.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1031.

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37. When developing a care plan for a client with a do-not-resuscitate (DNR) order, a nurse should:

Explanation

RATIONALE: Ensuring access to spiritual care, if requested by the client, is an appropriate nursing action. A nurse should continue to administer appropriate doses of pain medication as needed to promote the client's comfort. A health care provider may not withhold food and fluids unless the client has a living will that specifies this action. A health care provider may not legally administer lethal doses of medication under any circumstance.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 105.

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38. After a stroke, a client develops aphasia. The nurse expects to see which assessment finding?

Explanation

RATIONALE: Aphasia is the complete or partial loss of language skills caused by damage to cortical areas of the brain's left hemisphere. The client may have arm and leg weakness or an absent gag reflex after a stroke, but these findings aren't related to aphasia. Difficulty swallowing is called dysphagia.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 452.

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39. A client receives morphine, 4 mg I.V., for relief of surgical pain. Thirty minutes later, the nurse asks the client whether the pain is relieved. Which step of the nursing process is the nurse using?

Explanation

RATIONALE: Although the nurse is assessing pain relief, this action is considered part of evaluation, not assessment, because she's evaluating whether a performed intervention has met its goal. During the nursing diagnosis step of the nursing process, the nurse labels or describes the client's health problems or needs such as pain. During implementation, she attempts to meet the client's needs through such interventions as administering medication.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 213.

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40. A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?

Explanation

RATIONALE: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1007.

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41. When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be:

Explanation

RATIONALE: In Maslow's hierarchy of needs, pain relief is on the first layer. Love and belonging, as in allowing family members to visit are on the fourth layer. Activity, as in ambulation, is on the second layer. Safety, as in placing wrist restraints on the client, is on the third layer.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 29.

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42. Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation?

Explanation

RATIONALE: A variance is a deviation from what is expected on a critical pathway. An elevated temperature is a variance on the third postoperative day. A nurse must report the finding to the physician, who must determine source of the fever. Minimal serous drainage, intact skin over bony prominences, and intact staples are expected on the third post-operative day.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 664.

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43. An elderly client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client?

Explanation

RATIONALE: With age, the body's ability to regulate temperature diminishes and the number of sebaceous and sweat glands decreases. These changes put the elderly client at risk for Hyperthermia. Because hyperthermia can be life-threatening, this nursing diagnosis takes highest priority. If Activity intolerance, Disturbed thought processes, and Impaired physical mobility are relevant, the nurse should assign them lower priority when planning this client's care.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 560.

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44. Which option serves as a framework for nursing education and clinical practice?

Explanation

RATIONALE: Theoretical models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but aren't frameworks for nursing education and practice.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 85.

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45. A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?

Explanation

RATIONALE: Ineffective airway clearance related to anesthesia takes priority for this client because general anesthesia may impair a client's ability to clear secretions from his airway. Acute pain related to surgery, Deficient fluid volume related to blood and fluid loss from surgery, and Impaired physical mobility related to surgery, although important, are secondary.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 661.

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46. A nurse refers a client with terminal cancer to a local hospice. What is the goal of this referral?

Explanation

RATIONALE: Hospices provide supportive care for terminally ill clients and their families. Hospice care doesn't focus on counseling regarding health care costs. Most clients referred to hospices have been treated for their disease without success and will receive only palliative care in the hospice.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1329.

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47. On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3–, 28 mEq/L. Based on these values, the nurse should formulate which nursing diagnosis for this client?

Explanation

RATIONALE: The client's below-normal value for the partial pressure of arterial oxygen (PaO2) and an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2) support the nursing diagnosis of Impaired gas exchange. ABG values can't indicate a diagnosis of Fluid volume deficit (or excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical, not nursing, diagnosis; in any event, these ABG values indicate respiratory, not metabolic, acidosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 838.

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48. A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?

Explanation

RATIONALE: A client with renal failure can't eliminate sufficient fluid. This issue increases his risk of fluid overload and consequent respiratory and electrolyte problems. This client shows signs of excess fluid volume and is acutely ill. Urine retention may cause renal failure but is a less urgent concern than fluid imbalance. Fear and Toileting self-care deficit may also be appropriate nursing diagnoses but they take lower priority because they aren't life-threatening.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 942.

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49. Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?

Explanation

RATIONALE: According to Maslow, elimination is a first-level, or physiologic, need and therefore takes priority over all other needs. Inserting a Foley catheter helps meet the client's elimination need. Raising the side rails on the bed meets safety needs, which are a second-level need. Arranging a visit from a member of a support group and placing the client in a room with someone the same age meet the need for belonging and acceptance, which are third-level needs. Second- and third-level needs can be met only after the client's first-level needs have been satisfied.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 29.

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50. A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?

Explanation

RATIONALE: "The client remains free of signs and symptoms of phlebitis" is an appropriate expected outcome. Monitoring fluid intake and output is a nursing intervention. Edema and warmth are objective assessment findings. Risk for infection related to I.V. insertion is a nursing diagnosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 292.

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51. A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3–, 26 mEq/L. Based on these values, the nurse should suspect which condition?

Explanation

RATIONALE: This client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3–) values are below normal. In metabolic alkalosis, the pH and HCO3– values are above normal.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1685.

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52. A nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the client's blood?

Explanation

RATIONALE: The pH value in an ABG report reflects the acid concentration in the blood. The partial pressure of arterial oxygen (PaO2) value indicates the amount of oxygen dissolved in the blood; the partial pressure of arterial carbon dioxide (PaCO2) value represents the amount of carbon dioxide dissolved in the blood. The bicarbonate (HCO3–) value indicates the amount of bicarbonate, or base, in the blood.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1685.

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53. Each morning, a nurse-manager assigns clients and additional tasks for the staff nurses to complete that day. During the shift, a crisis develops and one staff nurse doesn't complete the additional tasks. The next day, the nurse-manager reprimands this nurse. When the nurse tries to explain, the nurse-manager interrupts, saying that the nurse should have completed the tasks no matter what happened. Which leadership style is the nurse-manager exhibiting?

Explanation

RATIONALE: An autocratic leader retains all authority and responsibility and is concerned primarily with completing tasks and meeting goals. A democratic leader is people-centered, allows greater individual participation in decision making, and maintains open communication. A permissive or laissez-faire leader denies responsibility and abdicates her authority to the group.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 535.

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54. A nurse may use one of many nursing theories to guide client care. What are the four key concepts of most nursing theories?

Explanation

RATIONALE: Most nursing theories deal with the key concepts of person (the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Specific theorists address the concepts of illness, health care, health restoration, caring, disease, and treatment.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 55.

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55. A client who is blind is admitted for treatment of gastroenteritis. Which nursing diagnosis takes highest priority for this client?

Explanation

RATIONALE: Because the client has gastroenteritis and is probably dehydrated, Deficient fluid volume takes highest priority. A sensory deficit such as blindness puts the client at risk for injury from the environment; however, a potential problem doesn't take highest priority. Although Activity intolerance or Impaired physical mobility also may be relevant, these nursing diagnoses don't take precedence over the client's dehydration.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1516.

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56. A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is:

Explanation

RATIONALE: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls — for example, if the client is confused. Even when the client needs assistance to get out of bed, the nurse should place the bed in the lowest position. The client may not require a bedpan.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 688.

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57. A nurse should expect to find which defining characteristics in a client with a nursing diagnosis of Ineffective tissue perfusion (peripheral)? Select all that apply.

Explanation

RATIONALE: Lack of oxygen to nourish tissues at the capillary level causes edema, discoloration, and changes in skin temperature. Pulses will be weak or absent, and the client will experience altered sensation. Pink skin color; strong, bounding pulses; and normal sensation are signs of adequate perfusion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 892.

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58. A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis?

Explanation

RATIONALE: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behavior. She should express that behavior in terms of client expectations and should indicate a time frame in which to accomplish it. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable outcomes. Understanding all complications of a disease process isn't measurable or specific to the nursing diagnosis listed.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 195.

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59. Which clinical characteristic affects client compliance?

Explanation

RATIONALE: Two major clinical characteristics affect client compliance: the nurse-client relationship and the therapeutic regimen. The client's drug knowledge, psychosocial factors, and disease duration and severity are client characteristics, not clinical ones.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 405.

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60. A student nurse requires additional teaching if she identifies which factor as contributing to a client's Risk for infection?

Explanation

RATIONALE: Malnutrition, rather than proper nutrient intake, would put the client at risk for infection. Inadequate secondary defenses, impaired primary defenses, and chronic disease put the client at risk by lowering the body's ability to fight infection.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1065.

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61. To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform?

Explanation

RATIONALE: The P wave depicts atrial depolarization, or spread of the electrical impulse from the sinoatrial node through the atria. The PR interval represents spread of the impulse through the interatrial and internodal fibers, atrioventricular node, bundle of His, and Purkinje fibers. The QRS complex represents ventricular depolarization. The T wave depicts the relative refractory period, representing ventricular repolarization.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 826.

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62. A nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for planning care?

Explanation

RATIONALE: Recognizing an individual's positive health measures is very useful. General health in the previous 10 years is important; however, the current activities of an 85-year-old client are most significant in planning care. Family history of diseases is of minor significance for a client in later years. Marital status information may be important for discharge planning but isn't as significant for addressing the immediate medical problem.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 601.

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63. A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order?

Explanation

RATIONALE: Because shock signals a severe fluid volume loss of (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. Monitoring urine output every hour, administering oxygen by nasal cannula at 3 L/minute, and drawing samples for hemoglobin and hematocrit every 6 hours are appropriate orders for this client.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 364.

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64. Which statement reflects appropriate documentation in the medical record of a hospitalized client?

Explanation

RATIONALE: Documentation should include data that the nurse obtains only by hearing, seeing, smelling, or feeling. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day doesn't provide precise enough information to be useful.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 238.

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65. When developing the teaching plan for a client who uses a walker, which principle should a nurse consider?

Explanation

RATIONALE: To prevent falls, a client who needs maximum support should move the walker ahead approximately 6″. The client's legs should bear the weight of his body. The hand bar of the walker should be level with the client's waist, not below it. If one leg is weaker than the other, the walker and the weak leg move together while the stronger leg bears the client's weight. To use a standard walker correctly, a client should pick it up to move it. However, some walkers have wheels and can glide across the floor.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 805.

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66. A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions?

Explanation

RATIONALE: Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care correctly. Asking whether the client understands the instructions isn't appropriate because clients may claim to understand discharge instructions when they don't. An interpreter or family member may communicate verbal or written instructions inaccurately.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 414.

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67. Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down his left arm. The nurse notes that the client is restless and slightly diaphoretic, and measures a temperature of 99.6° F (37.6° C); a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes highest priority?

Explanation

RATIONALE: The nursing diagnosis of Acute pain takes highest priority because it increases the client's pulse and blood pressure. During the acute phase of an MI, low-grade fever is an expected result of the body's response to myocardial tissue necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis, but addressing Acute pain (the priority concern) may alleviate the client's anxiety.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 880.

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68. A client with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the client is short of breath and the nurse notes bilateral crackles, jugular vein distention, and tachycardia. What should the nurse do first?

Explanation

RATIONALE: Because this client has fluid overload, the nurse should first slow the infusion to prevent additional fluid overload, then notify the physician and obtain further orders. Notifying the physician without slowing the infusion would put the client at risk for pulmonary complications or respiratory failure. Discontinuing the catheter is inappropriate because the nurse may still need vascular access to administer I.V. fluids (at a decreased rate) or additional I.V. medications. Administering a diuretic without changing the I.V. infusion rate wouldn't prevent fluid overload from recurring.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 626.

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69. The nurse is reviewing sterile procedures with a student nurse. The nurse understands that the student requires additional teaching when the student identifies which procedure as requiring sterile technique?

Explanation

RATIONALE: The GI system isn't a sterile system; therefore, NG tube placement doesn't require sterile technique. I.V. insertion requires sterile technique because intentional penetration of the skin occurs. The urinary system is sterile, so the nurse must maintain sterility during catheter placement. Burns have a high risk for infection; the nurse must maintain sterile technique to decrease this risk.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 532.

Submit
70. A client is admitted with the following vital signs: temperature, 102° F (38.9° C); heart rate, 144 beats/minute and irregular; and respiratory rate, 26 breaths/minute. Which nursing diagnosis takes highest priority when planning this client's care?

Explanation

RATIONALE: A heart rate of 144 beats/minute indicates decreased diastolic filling time and a reduced blood volume ejected with each contraction, resulting in decreased cardiac output. The client's temperature and respiratory rate are elevated but not enough for a diagnosis of Ineffective thermoregulation or Ineffective breathing pattern to take precedence over one of Decreased cardiac output. The client's vital signs don't suggest a diagnosis of Ineffective renal tissue perfusion.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 885.

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71. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

Explanation

RATIONALE: Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1364.

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72. A nurse identifies a client's responses to actual or potential health problems during which step of the nursing process?

Explanation

RATIONALE: The nurse identifies human responses to actual or potential health problems during the diagnosis step of the nursing process, which encompasses the nurse's ability to formulate a nursing diagnosis. During the assessment step, the nurse systematically collects data about the client or his family. During the planning step, she develops strategies to resolve or decrease the client's problem. During the evaluation step, the nurse determines the effectiveness of the care plan.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 146.

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73. A nurse is caring for a client with a central venous pressure (CVP) of 4 mm Hg. Which nursing intervention is appropriate?

Explanation

RATIONALE: Normal CVP ranges from 3 to 7 mm Hg. The nurse doesn't need to take any action other than to monitor the client. It isn't necessary to rezero the equipment. Calling a physician and obtaining an order for a fluid bolus would be an appropriate intervention if the client has a CVP less than 3 mm Hg. Administering a diuretic would be appropriate if the client had excess fluid, as demonstrated by a CVP greater than 7 mm Hg.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 816.

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74. A nurse is providing preoperative teaching to a client. Which type of evaluation should the nurse use in this situation?

Explanation

RATIONALE: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. Summative, or retrospective, evaluation occurs at the conclusion of the teaching and learning session. Informative isn't a type of evaluation.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 522.

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  • Mar 21, 2022
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  • Nov 01, 2015
    Quiz Created by
    Suarezenriquec1
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When caring for a client, a nurse must determine whether the client...
When performing an assessment, the nurse identifies the following...
A client is admitted to the health care facility with bowel...
During the planning step of the nursing process, the nurse:
A client is scheduled for surgery under general anesthesia. The night...
Which component of an outcome criterion must the nurse consider when...
While caring for a client who's immobile, a nurse documents the...
A client is admitted to the health care facility after 3 days of...
After assessing a client, a nurse formulates relevant nursing...
When obtaining a client's history, the nurse should:
When documenting information in a client's medical record, the...
One aspect of implementation related to drug therapy is:
A client with heart failure hasn't slept for the past 3 nights...
A nurse is changing a client's dressing. Which observation of the...
A nurse is revising a client's care plan. During which step of the...
A client is admitted to the health care facility with acute chest...
During the planning step of the nursing process, the nurse:
Which client characteristic is an example of noncompliance?
Which source of information helps a nurse formulate nursing diagnoses...
A nurse is caring for a client with a diagnosis of Impaired gas...
The daughter of an alert and oriented elderly client asks what her...
A client is hospitalized with Pneumocystis carinii pneumonia. A nurse...
A nurse is providing care for a client who underwent mitral valve...
A client is breathing 40 breaths/minute. He is diaphoretic and...
Which intervention is an example of primary prevention?
When developing a care plan for an older adult, a nurse should...
A nurse is developing a nursing diagnosis for a client. Which...
A client with acquired immunodeficiency syndrome (AIDS) develops...
A client is to be discharged from an acute care facility after...
What is a common goal of discharge planning in all care settings?
What is the best way for a nurse to maintain security when using...
The following statement appears on a client's care plan:...
A client complains of severe abdominal pain. To elicit as much...
Which type of nursing intervention does the nurse perform when she...
When implementing the planned care of a client with pneumonia, a nurse...
A client is placed on a low-sodium (500 mg/day) diet. Which client...
When developing a care plan for a client with a do-not-resuscitate...
After a stroke, a client develops aphasia. The nurse expects to see...
A client receives morphine, 4 mg I.V., for relief of surgical pain....
A client is diagnosed with deep vein thrombosis (DVT). Which nursing...
When prioritizing a client's care plan based on Maslow's...
Which finding is an example of a variance in the critical pathway of a...
An elderly client is admitted to the facility after fainting while...
Which option serves as a framework for nursing education and clinical...
A client who received general anesthesia returns from surgery....
A nurse refers a client with terminal cancer to a local hospice. What...
On admission, a client has the following arterial blood gas (ABG)...
A client with chronic renal failure is admitted with a heart rate of...
Using Abraham Maslow's hierarchy of human needs, the nurse assigns...
A client has been receiving an I.V. solution. What is an appropriate...
A client has the following arterial blood gas values: pH, 7.30; PaO2,...
A nurse is reviewing a client's arterial blood gas (ABG) report....
Each morning, a nurse-manager assigns clients and additional tasks for...
A nurse may use one of many nursing theories to guide client care....
A client who is blind is admitted for treatment of gastroenteritis....
A nurse is caring for a client with a history of falls. The...
A nurse should expect to find which defining characteristics in a...
A client has a nursing diagnosis of Risk for injury related to adverse...
Which clinical characteristic affects client compliance?
A student nurse requires additional teaching if she identifies which...
To evaluate a client's atrial depolarization, the nurse observes...
A nurse is taking the health history of an 85-year-old client. Which...
A client with shock brought on by hemorrhage has a temperature of...
Which statement reflects appropriate documentation in the medical...
When developing the teaching plan for a client who uses a walker,...
A client who speaks little English has emergency gallbladder surgery....
Shortly after being admitted to the coronary care unit with an acute...
A client with heart failure has been receiving an I.V. infusion at 125...
The nurse is reviewing sterile procedures with a student nurse. The...
A client is admitted with the following vital signs: temperature,...
What is the most appropriate nursing diagnosis for the client with...
A nurse identifies a client's responses to actual or potential...
A nurse is caring for a client with a central venous pressure (CVP) of...
A nurse is providing preoperative teaching to a client. Which type of...
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