The Nursing Process
74 Questions
| Attempts: 425
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Questions and Answers
- 1.
After assessing a client, a nurse formulates relevant nursing diagnoses. Which statement is a complete nursing diagnosis statement?
- A.
Ineffective airway clearance related to mucus plugs and nonproductive cough
- B.
Hyperventilation related to anxiety
- C.
Tachycardia
- D.
Shortness of breath related to anxiety
Correct Answer
A. Ineffective airway clearance related to mucus plugs and nonproductive coughExplanation
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.Rate this question:
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- 2.
A nurse may use one of many nursing theories to guide client care. What are the four key concepts of most nursing theories?
- A.
Person, health, illness, and health care
- B.
Health, illness, health restoration, and caring
- C.
Person, environment, health, and nursing
- D.
Health, environment, disease, and treatment
Correct Answer
C. Person, environment, health, and nursingExplanation
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.Rate this question:
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- 3.
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.
- A.
Edema
- B.
Skin pink in color
- C.
Strong, bounding pulses
- D.
Normal sensation
- E.
Skin discoloration
- F.
Skin temperature changes
Correct Answer(s)
A. Edema
E. Skin discoloration
F. Skin temperature changesExplanation
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.Rate this question:
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- 4.
Which type of nursing intervention does the nurse perform when she administers oral care to a client?
- A.
Psychomotor
- B.
Educational
- C.
Maintenance
- D.
Supervisory
Correct Answer
C. MaintenanceExplanation
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.Rate this question:
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- 5.
What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
- A.
Deficient fluid volume
- B.
Excess fluid volume
- C.
Decreased cardiac output
- D.
Ineffective gastrointestinal tissue perfusion
Correct Answer
A. Deficient fluid volumeExplanation
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.Rate this question:
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- 6.
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?
- A.
Risk for impaired skin integrity related to immobility
- B.
Impaired skin integrity related to immobility
- C.
Constipation related to immobility
- D.
Disturbed body image related to immobility
Correct Answer
A. Risk for impaired skin integrity related to immobilityExplanation
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.Rate this question:
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- 7.
One aspect of implementation related to drug therapy is:
- A.
Developing a content outline.
- B.
Documenting drugs given.
- C.
Establishing outcome criteria.
- D.
Setting realistic client goals.
Correct Answer
B. 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.Rate this question:
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- 8.
A nurse is developing a nursing diagnosis for a client. Which information should she include?
- A.
Actions to achieve goals
- B.
Expected outcomes
- C.
Factors influencing the client's problem
- D.
Nursing history
Correct Answer
C. Factors influencing the client's problemExplanation
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.Rate this question:
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- 9.
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?
- A.
Deficient knowledge related to food restrictions associated with anesthesia
- B.
Fear related to surgery
- C.
Risk for impaired skin integrity related to upcoming surgery
- D.
Ineffective coping related to the stress of surgery
Correct Answer
A. Deficient knowledge related to food restrictions associated with anesthesiaExplanation
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.Rate this question:
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- 10.
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?
- A.
Planning
- B.
Assessment
- C.
Evaluation
- D.
Implementation
Correct Answer
B. AssessmentExplanation
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.Rate this question:
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- 11.
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?
- A.
Risk for deficient fluid volume
- B.
Deficient fluid volume
- C.
Impaired gas exchange
- D.
Metabolic acidosis
Correct Answer
C. Impaired gas exchangeExplanation
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.Rate this question:
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- 12.
During the planning step of the nursing process, the nurse:
- A.
Determines the client's goal achievement.
- B.
Writes a statement about the client's health problem.
- C.
Establishes short- and long-term goals.
- D.
Gathers objective data.
Correct Answer
C. 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.Rate this question:
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- 13.
During the planning step of the nursing process, the nurse:
- A.
Records data.
- B.
Selects interventions.
- C.
Collects data.
- D.
Carries out interventions.
Correct Answer
B. 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.Rate this question:
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- 14.
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?
- A.
"I can still eat a ham-and-cheese sandwich with potato chips for lunch."
- B.
"I chose broiled chicken with a baked potato for dinner."
- C.
"I chose a tossed salad with sardines and oil and vinegar dressing for lunch."
- D.
"I'm glad I can still have chicken bouillon."
Correct Answer
B. "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.Rate this question:
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- 15.
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?
- A.
Fatigue
- B.
Impaired gas exchange
- C.
Activity intolerance
- D.
Insomnia
Correct Answer
B. Impaired gas exchangeExplanation
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.Rate this question:
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- 16.
Which option serves as a framework for nursing education and clinical practice?
- A.
Scientific breakthroughs
- B.
Technological advances
- C.
Theoretical models
- D.
Medical practices
Correct Answer
C. Theoretical modelsExplanation
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.Rate this question:
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- 17.
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?
- A.
"By discharge, the client correctly identifies three potassium-rich food sources."
- B.
"The client knows the importance of consuming potassium-rich foods daily."
- C.
"Before discharge, the client knows which food sources are high in potassium."
- D.
"The client understands all complications of the disease process."
Correct Answer
A. "By discharge, the client correctly identifies three potassium-rich food sources."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.Rate this question:
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- 18.
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?
- A.
Risk for imbalanced body temperature
- B.
Decreased cardiac output
- C.
Anxiety
- D.
Acute pain
Correct Answer
D. Acute painExplanation
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.Rate this question:
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- 19.
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?
- A.
Identifying one way to increase his social interaction
- B.
Reporting increased adaptation to changes in his health status
- C.
Identifying at least one factor contributing to the client's altered sexuality patterns
- D.
Giving a demonstration of measures that can increase independence
Correct Answer
A. Identifying one way to increase his social interactionExplanation
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.Rate this question:
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- 20.
A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
- A.
Acute pain related to surgery
- B.
Deficient fluid volume related to blood and fluid loss from surgery
- C.
Impaired physical mobility related to surgery
- D.
Ineffective airway clearance related to anesthesia
Correct Answer
D. Ineffective airway clearance related to anesthesiaExplanation
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.Rate this question:
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- 21.
After a stroke, a client develops aphasia. The nurse expects to see which assessment finding?
- A.
Arm and leg weakness
- B.
Absence of the gag reflex
- C.
Difficulty swallowing
- D.
Inability to speak clearly
Correct Answer
D. Inability to speak clearlyExplanation
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.Rate this question:
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- 22.
Which intervention is an example of primary prevention?
- A.
Administering digoxin (Lanoxicaps) to a client with heart failure
- B.
Administering a measles, mumps, and rubella immunization to an infant
- C.
Obtaining a Papanicolaou (Pap) test to screen for cervical cancer
- D.
Using occupational therapy to help a client cope with arthritis
Correct Answer
B. Administering a measles, mumps, and rubella immunization to an infantExplanation
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.Rate this question:
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- 23.
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?
- A.
Impaired gas exchange related to increased blood flow
- B.
Excess fluid volume related to peripheral vascular disease
- C.
Risk for injury related to edema
- D.
Ineffective peripheral tissue perfusion related to venous congestion
Correct Answer
D. Ineffective peripheral tissue perfusion related to venous congestionExplanation
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.Rate this question:
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- 24.
A nurse identifies a client's responses to actual or potential health problems during which step of the nursing process?
- A.
Assessment
- B.
Diagnosis
- C.
Planning
- D.
Evaluation
Correct Answer
B. DiagnosisExplanation
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.Rate this question:
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- 25.
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:
- A.
Pulling the ear pinna back, up, and out.
- B.
Pulling the ear pinna back, down, and out.
- C.
Pulling the ear pinna out.
- D.
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.Rate this question:
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- 26.
A nurse is providing preoperative teaching to a client. Which type of evaluation should the nurse use in this situation?
- A.
Formative
- B.
Retrospective
- C.
Summative
- D.
Informative
Correct Answer
A. FormativeExplanation
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.Rate this question:
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- 27.
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?
- A.
Asking frequently whether the client understands the instructions
- B.
Asking an interpreter to relay the instructions to the client
- C.
Writing out the instructions and having a family member read them to the client
- D.
Demonstrating the procedure and having the client return the demonstration
Correct Answer
D. Demonstrating the procedure and having the client return the demonstrationExplanation
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.Rate this question:
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- 28.
Which client characteristic is an example of noncompliance?
- A.
Undesired drug action
- B.
Multiple questions
- C.
Failure to progress
- D.
Resolved symptoms
Correct Answer
C. Failure to progressExplanation
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.Rate this question:
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- 29.
When developing a care plan for a client with a do-not-resuscitate (DNR) order, a nurse should:
- A.
Withhold food and fluids.
- B.
Discontinue pain medications as ordered.
- C.
Ensure access to individuals who can provide spiritual care in accordance with a client's request.
- D.
Administer lethal doses of medications when requested to do so by a competent, terminally ill client.
Correct Answer
C. 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.Rate this question:
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- 30.
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?
- A.
Hyperthermia
- B.
Activity intolerance
- C.
Disturbed thought processes
- D.
Impaired physical mobility
Correct Answer
A. HyperthermiaExplanation
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.Rate this question:
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- 31.
When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be:
- A.
Allowing family members to visit a newly admitted client.
- B.
Ambulating the client in the hallway.
- C.
Administering pain medication.
- D.
Placing wrist restraints on the client.
Correct Answer
C. 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.Rate this question:
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- 32.
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?
- A.
Insomnia
- B.
Anxiety
- C.
Risk for injury due to confusion
- D.
Impaired gas exchange
Correct Answer
D. Impaired gas exchangeExplanation
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.Rate this question:
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- 33.
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?
- A.
General health for the past 10 years
- B.
Current health promotion activities
- C.
Family history of diseases
- D.
Marital status
Correct Answer
B. Current health promotion activitiesExplanation
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.Rate this question:
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- 34.
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?
- A.
I.V. insertion
- B.
Nasogastric (NG) tube placement
- C.
Urinary catheterization
- D.
Wound care involving burns
Correct Answer
B. Nasogastric (NG) tube placementExplanation
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.Rate this question:
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- 35.
Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?
- A.
Arranging a visit from a support group member
- B.
Inserting a Foley catheter
- C.
Raising the side rails on the client's bed
- D.
Placing the client in a double room with another client the same age
Correct Answer
B. Inserting a Foley catheterExplanation
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.Rate this question:
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- 36.
Which statement reflects appropriate documentation in the medical record of a hospitalized client?
- A.
"Small pressure ulcer noted on left leg."
- B.
"Client seems to be mad at the physician."
- C.
"Client had a good day."
- D.
"Client's skin is moist and cool."
Correct Answer
D. "Client's skin is moist and cool."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.Rate this question:
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- 37.
A client who is blind is admitted for treatment of gastroenteritis. Which nursing diagnosis takes highest priority for this client?
- A.
Deficient fluid volume
- B.
Risk for injury
- C.
Activity intolerance
- D.
Impaired physical mobility
Correct Answer
A. Deficient fluid volumeExplanation
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.Rate this question:
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- 38.
A nurse is revising a client's care plan. During which step of the nursing process does she make such revisions?
- A.
Assessment
- B.
Planning
- C.
Implementation
- D.
Evaluation
Correct Answer
D. EvaluationExplanation
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.Rate this question:
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- 39.
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?
- A.
Decreased cardiac output
- B.
Ineffective thermoregulation
- C.
Ineffective breathing pattern
- D.
Ineffective renal tissue perfusion
Correct Answer
A. Decreased cardiac outputExplanation
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.Rate this question:
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- 40.
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?
- A.
"Monitor urine output every hour."
- B.
"Infuse I.V. fluids at 83 ml/hour."
- C.
"Administer oxygen by nasal cannula at 3 L/minute."
- D.
"Draw samples for hemoglobin and hematocrit every 6 hours."
Correct Answer
B. "Infuse I.V. fluids at 83 ml/hour."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.Rate this question:
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- 41.
When developing a care plan for an older adult, a nurse should consider which challenges that clients in this age-group face?
- A.
Selecting vocation, becoming financially independent, and managing a home
- B.
Developing leisure activities, preparing for retirement, and resolving empty-nest crises
- C.
Managing a home, developing leisure activities, and preparing for retirement
- D.
Adjusting to retirement, deaths of family members, and decreased physical strength
Correct Answer
D. Adjusting to retirement, deaths of family members, and decreased physical strengthExplanation
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.Rate this question:
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- 42.
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?
- A.
Assessment
- B.
Diagnosis
- C.
Implementation
- D.
Evaluation
Correct Answer
D. EvaluationExplanation
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.Rate this question:
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- 43.
Which clinical characteristic affects client compliance?
- A.
Drug knowledge
- B.
Psychosocial factors
- C.
The nurse-client relationship
- D.
Disease duration and severity
Correct Answer
C. The nurse-client relationshipExplanation
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.Rate this question:
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- 44.
A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?
- A.
Impaired gas exchange
- B.
Impaired oral mucous membranes
- C.
Imbalanced nutrition: Less than body requirements
- D.
Activity intolerance
Correct Answer
A. Impaired gas exchangeExplanation
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.Rate this question:
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- 45.
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?
- A.
Assessment
- B.
Analysis
- C.
Implementation
- D.
Evaluation
Correct Answer
D. EvaluationExplanation
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.Rate this question:
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- 46.
Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation?
- A.
Temperature of 102° F (37.7° C)
- B.
Minimal serous wound drainage
- C.
Skin intact over bony prominences
- D.
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.Rate this question:
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- 47.
A student nurse requires additional teaching if she identifies which factor as contributing to a client's Risk for infection?
- A.
Inadequate secondary defenses, such as decreased hemoglobin, leukopenia, and immunosuppression
- B.
Impairment of primary body system defenses, such as decreased ciliary action, broken skin, or stasis of body fluids
- C.
Chronic disease
- D.
Proper nutrient intake
Correct Answer
D. Proper nutrient intakeExplanation
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.Rate this question:
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- 48.
What is a common goal of discharge planning in all care settings?
- A.
Prolonging hospitalization until the client can function independently
- B.
Providing continuity of care for the client
- C.
Providing the financial resources needed to ensure proper care
- D.
Preventing the need for medical follow-up care
Correct Answer
B. Providing continuity of care for the clientExplanation
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.Rate this question:
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- 49.
Which source of information helps a nurse formulate nursing diagnoses for a specific client?
- A.
Research articles
- B.
Essential assessment data
- C.
Outcome criteria
- D.
Admission criteria
Correct Answer
B. Essential assessment dataExplanation
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.Rate this question:
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- 50.
Which component of an outcome criterion must the nurse consider when setting goals for a client?
- A.
A place
- B.
A family member
- C.
A focal point
- D.
A time frame
Correct Answer
D. A time frameExplanation
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.Rate this question:
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