The Nursing Process

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    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?

    • Evaluation
    • Planning
    • Implementation
    • Assessment
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The Nursing Process - Quiz

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  • 2. 

    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?

    • Planning

    • Assessment

    • Evaluation

    • Implementation

    Correct Answer
    A. Assessment
    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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  • 3. 

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

    • Records data.

    • Selects interventions.

    • Collects data.

    • Carries out interventions.

    Correct Answer
    A. Selects interventions.
    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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  • 4. 

    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?

    • Health-seeking behaviors

    • Impaired physical mobility

    • Disturbed sensory perception

    • Deficient knowledge

    Correct Answer
    A. Impaired physical mobility
    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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  • 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?

    • Deficient knowledge related to food restrictions associated with anesthesia

    • Fear related to surgery

    • Risk for impaired skin integrity related to upcoming surgery

    • Ineffective coping related to the stress of surgery

    Correct Answer
    A. Deficient knowledge related to food restrictions associated with anesthesia
    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?

    • A place

    • A family member

    • A focal point

    • A time frame

    Correct Answer
    A. A time frame
    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?

    • Risk for impaired skin integrity related to immobility

    • Impaired skin integrity related to immobility

    • Constipation related to immobility

    • Disturbed body image related to immobility

    Correct Answer
    A. Risk for impaired skin integrity related to immobility
    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. 

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

    • Ineffective airway clearance related to mucus plugs and nonproductive cough

    • Hyperventilation related to anxiety

    • Tachycardia

    • Shortness of breath related to anxiety

    Correct Answer
    A. Ineffective airway clearance related to mucus plugs and nonproductive cough
    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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  • 9. 

    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?

    • Excessive fluid volume related to intracellular fluid shift

    • Imbalanced nutrition: Less than body requirements related to decreased intake

    • Deficient fluid volume related to nausea and vomiting

    • Ineffective cardiopulmonary tissue perfusion related to hyperventilation

    Correct Answer
    A. Deficient fluid volume related to nausea and vomiting
    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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  • 10. 

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

    • Ask questions about the client's reason for seeking care.

    • Palpate the client's abdomen.

    • Auscultate for the client's breath sounds.

    • Document medication administered.

    Correct Answer
    A. Ask questions about the client's reason for seeking care.
    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:

    • Erase any errors.

    • Use a #2 pencil.

    • Leave one line blank before each new entry.

    • End each entry with her signature and title.

    Correct Answer
    A. End each entry with her signature and title.
    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:

    • Developing a content outline.

    • Documenting drugs given.

    • Establishing outcome criteria.

    • Setting realistic client goals.

    Correct Answer
    A. Documenting drugs given.
    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?

    • Fatigue

    • Impaired gas exchange

    • Activity intolerance

    • Insomnia

    Correct Answer
    A. Impaired gas exchange
    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?

    • Approximated wound edges

    • Yellow, purulent drainage

    • Sutures in place

    • Pink granulation tissue

    Correct Answer
    A. Yellow, purulent drainage
    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?

    • Assessment

    • Planning

    • Implementation

    • Evaluation

    Correct Answer
    A. Evaluation
    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. 

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

    • Determines the client's goal achievement.

    • Writes a statement about the client's health problem.

    • Establishes short- and long-term goals.

    • Gathers objective data.

    Correct Answer
    A. Establishes short- and long-term goals.
    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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  • 17. 

    Which client characteristic is an example of noncompliance?

    • Undesired drug action

    • Multiple questions

    • Failure to progress

    • Resolved symptoms

    Correct Answer
    A. Failure to progress
    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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  • 18. 

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

    • Research articles

    • Essential assessment data

    • Outcome criteria

    • Admission criteria

    Correct Answer
    A. Essential assessment data
    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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  • 19. 

    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?

    • "Do you need anything now?"

    • "Why do you think you had a heart attack?"

    • "What were you doing when the pain started?"

    • "Has anyone in your family been sick lately?"

    Correct Answer
    A. "What were you doing when the pain started?"
    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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  • 20. 

    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:

    • Tell the client's daughter his blood glucose level because this test is performed on the nursing unit.

    • Ask the client's daughter if she has her father's permission to have access to his health information.

    • Check the nurses' notes to see if others have given the client's daughter this information.

    • Explain that under Health Insurance Portability and Accountability Act (HIPAA) regulations, she can't disclose this information without the client's permission.

    Correct Answer
    A. Explain that under Health Insurance Portability and Accountability Act (HIPAA) regulations, she can't disclose this information without the client's permission.
    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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  • 21. 

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

    • The client maintains a reduced cough effort to lessen fatigue.

    • The client restricts fluid intake to prevent overhydration.

    • The client reduces daily activities to a minimum.

    • The client has normal breath sounds in all lung fields.

    Correct Answer
    A. The client has normal breath sounds in all lung fields.
    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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  • 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?

    • Identifying one way to increase his social interaction

    • Reporting increased adaptation to changes in his health status

    • Identifying at least one factor contributing to the client's altered sexuality patterns

    • Giving a demonstration of measures that can increase independence

    Correct Answer
    A. Identifying one way to increase his social interaction
    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. 

    Which intervention is an example of primary prevention?

    • Administering digoxin (Lanoxicaps) to a client with heart failure

    • Administering a measles, mumps, and rubella immunization to an infant

    • Obtaining a Papanicolaou (Pap) test to screen for cervical cancer

    • Using occupational therapy to help a client cope with arthritis

    Correct Answer
    A. Administering a measles, mumps, and rubella immunization to an infant
    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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  • 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?

    • Insomnia

    • Anxiety

    • Risk for injury due to confusion

    • Impaired gas exchange

    Correct Answer
    A. Impaired gas exchange
    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. 

    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:

    • Change his own dressing.

    • Walk in the hallway.

    • Walk from his room to the end of the hall and back before discharge.

    • Eat a special diet.

    Correct Answer
    A. Walk from his room to the end of the hall and back before discharge.
    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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  • 26. 

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

    • Selecting vocation, becoming financially independent, and managing a home

    • Developing leisure activities, preparing for retirement, and resolving empty-nest crises

    • Managing a home, developing leisure activities, and preparing for retirement

    • Adjusting to retirement, deaths of family members, and decreased physical strength

    Correct Answer
    A. Adjusting to retirement, deaths of family members, and decreased physical strength
    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?

    • Actions to achieve goals

    • Expected outcomes

    • Factors influencing the client's problem

    • Nursing history

    Correct Answer
    A. Factors influencing the client's problem
    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?

    • Impaired gas exchange

    • Impaired oral mucous membranes

    • Imbalanced nutrition: Less than body requirements

    • Activity intolerance

    Correct Answer
    A. Impaired gas exchange
    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?

    • Assessment

    • Analysis

    • Implementation

    • Evaluation

    Correct Answer
    A. Evaluation
    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?

    • Prolonging hospitalization until the client can function independently

    • Providing continuity of care for the client

    • Providing the financial resources needed to ensure proper care

    • Preventing the need for medical follow-up care

    Correct Answer
    A. Providing continuity of care for the client
    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. 

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

    • Psychomotor

    • Educational

    • Maintenance

    • Supervisory

    Correct Answer
    A. Maintenance
    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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  • 32. 

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

    • A nurse should give her computer access code only to health care personnel directly involved in client care.

    • A nurse may leave the computer logged in for use by other health care personnel directly involved in a client's care.

    • A nurse shouldn't give her computer access code to other health care personnel involved in direct client care.

    • A nurse may give her computer access code to nurses on the following shift who are caring for the same clients.

    Correct Answer
    A. A nurse shouldn't give her computer access code to other health care personnel involved in direct client care.
    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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  • 33. 

    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:

    • A nursing diagnosis.

    • A client outcome.

    • Subjective data.

    • A nursing intervention.

    Correct Answer
    A. A client outcome.
    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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  • 34. 

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

    • "Do you have the pain all the time?"

    • "Can you describe the pain?"

    • "Where does it hurt the most?"

    • "Is the pain stabbing like a knife?"

    Correct Answer
    A. "Can you describe the pain?"
    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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  • 35. 

    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?

    • "I can still eat a ham-and-cheese sandwich with potato chips for lunch."

    • "I chose broiled chicken with a baked potato for dinner."

    • "I chose a tossed salad with sardines and oil and vinegar dressing for lunch."

    • "I'm glad I can still have chicken bouillon."

    Correct Answer
    A. "I chose broiled chicken with a baked potato for dinner."
    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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  • 36. 

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

    • Arm and leg weakness

    • Absence of the gag reflex

    • Difficulty swallowing

    • Inability to speak clearly

    Correct Answer
    A. Inability to speak clearly
    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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  • 37. 

    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:

    • Pulling the ear pinna back, up, and out.

    • Pulling the ear pinna back, down, and out.

    • Pulling the ear pinna out.

    • Pulling the ear pinna down.

    Correct Answer
    A. Pulling the ear pinna back, up, and out.
    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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  • 38. 

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

    • Withhold food and fluids.

    • Discontinue pain medications as ordered.

    • Ensure access to individuals who can provide spiritual care in accordance with a client's request.

    • Administer lethal doses of medications when requested to do so by a competent, terminally ill client.

    Correct Answer
    A. Ensure access to individuals who can provide spiritual care in accordance with a client's request.
    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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  • 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?

    • Assessment

    • Diagnosis

    • Implementation

    • Evaluation

    Correct Answer
    A. Evaluation
    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?

    • Impaired gas exchange related to increased blood flow

    • Excess fluid volume related to peripheral vascular disease

    • Risk for injury related to edema

    • Ineffective peripheral tissue perfusion related to venous congestion

    Correct Answer
    A. Ineffective peripheral tissue perfusion related to venous congestion
    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:

    • Allowing family members to visit a newly admitted client.

    • Ambulating the client in the hallway.

    • Administering pain medication.

    • Placing wrist restraints on the client.

    Correct Answer
    A. Administering pain medication.
    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?

    • Temperature of 102° F (37.7° C)

    • Minimal serous wound drainage

    • Skin intact over bony prominences

    • Staples intact to incision

    Correct Answer
    A. Temperature of 102° F (37.7° C)
    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?

    • Hyperthermia

    • Activity intolerance

    • Disturbed thought processes

    • Impaired physical mobility

    Correct Answer
    A. Hyperthermia
    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?

    • Scientific breakthroughs

    • Technological advances

    • Theoretical models

    • Medical practices

    Correct Answer
    A. Theoretical models
    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?

    • Acute pain related to surgery

    • Deficient fluid volume related to blood and fluid loss from surgery

    • Impaired physical mobility related to surgery

    • Ineffective airway clearance related to anesthesia

    Correct Answer
    A. Ineffective airway clearance related to anesthesia
    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. 

    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?

    • Risk for deficient fluid volume

    • Deficient fluid volume

    • Impaired gas exchange

    • Metabolic acidosis

    Correct Answer
    A. Impaired gas exchange
    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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  • 47. 

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

    • To help the client and his family cope with terminal illness

    • To ensure that the client gets counseling regarding health care costs

    • To teach the client and his family about cancer and its treatment

    • To help the client find appropriate treatment options

    Correct Answer
    A. To help the client and his family cope with terminal illness
    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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  • 48. 

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

    • Arranging a visit from a support group member

    • Inserting a Foley catheter

    • Raising the side rails on the client's bed

    • Placing the client in a double room with another client the same age

    Correct Answer
    A. Inserting a Foley catheter
    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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  • 49. 

    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?

    • Fear

    • Urinary retention

    • Excess fluid volume

    • Toileting self-care deficit

    Correct Answer
    A. Excess fluid volume
    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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