NURSING 1023 The nursing process Complete

NURSING 1023 The nursing process While caring for a client who's immobile, the 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." When creating the nursing care plan, which diagnosis would the nurse select to accurately reflect this information? Correct response: • Risk for impaired skin integrity related to immobility After collecting data on a client, the nurse helps formulate relevant nursing diagnoses. Which is a complete nursing diagnosis statement that the nurse would suggest be implemented? Correct response: • Ineffective airway clearance related to mucus plugs and nonproductive cough A nurse is reviewing the care plan of a client who has been receiving an intravenous solution. What appropriate expected outcome for this client should the nurse expect to find on the care plan? Correct response: • "The client remains free of signs and symptoms of phlebitis." Which statement reflects appropriate documentation in the medical record of a hospitalized client? Correct response: • "Client's skin is moist and cool." A newly hired graduate nurse asks her preceptor, "What is a common goal of discharge planning in all care settings?" How does the preceptor correctly respond? Correct response: • "The goal is teaching the client how to perform self-care activities." After a stroke, a client develops aphasia. The nurse expects to observe which data collection finding in this client? Correct response: • Inability to speak clearly Each morning, the nurse-manager assigns clients and additional tasks for the staff nurses to complete that day. During the shift, a crisis develops and one staff nurse does not complete the additional tasks. The next day, the nurse-manager reprimands this nurse. When the nurse tries to explain, the nurse-manager interrupts, saying that the tasks should have been completed regardless. The nurse recognizes which of the following leadership style the nurse-manager is exhibiting? Correct response: • Authoritarian A nurse is seen accessing a client's medical record in an area where she doesn't provide care. Which action by the nurse is best? Correct response: • Notify the charge nurse and nursing supervisor of the incident. A client with a weak left leg is learning how to ambulate with a cane; however, he has difficulty remembering to hold the cane with his right arm. Which statement by the nurse would be most helpful to this client? Correct response: • "Remember to hold the cane with the hand on the opposite side of your weak leg." Professional regulations and laws that govern nursing practice are in place for what reason? Correct response: • to protect the safety of the public An LPN is assigned to care for eight clients. Two unlicensed assistive personnel are assigned to work with this nurse. The LPN integrates understanding of which statement when delegating client care assignments to the unlicensed assistive personnel? Correct response: • The nurse is responsible for supervising the two unlicensed assistive personnel. A licensed practical nurse (LPN) is providing care to a client and is uncertain about a health care provider’s prescription regarding a medication prescribed for the client. Which action would be most appropriate? Correct response: • Decide whether to follow the prescription after conferring with the supervising registered nurse (RN). A nurse is caring for a 7-year-old child with Down syndrome. What action should the nurse take when assisting with the plan of care for this child? Correct response: • Evaluate the child's current developmental level and plan care accordingly. A 5-month-old infant is brought to the pediatric clinic by the parent. The child has had recurrent middle-ear infections since 3 months of age. Which information is most important for the nurse to collect at today's visit? Correct response: • whether the child received all the prescribed antibiotic at the time of the last infection A nurse is administering tobramycin to a client. Which adverse effect should the nurse ask the client to report? Correct response: • diminished hearing Which nursing intervention should the nurse give highest priority to when caring for an unconscious client? Correct response: • positioning the client with the head of bed at a 15 to 30 degree angle A nurse is assigned to care for a client in the immediate postoperative recovery phase. Which data collection takes priority during the initial assessment? Correct response: • airway, respiratory rate and depth, other vital signs, and skin color A nurse is assisting a primary health care provider perform a lumbar puncture. The client appears worried and anxious. After the procedure, which statement is most appropriate for the nurse to make? Correct response: • "I want you to lie flat for a while. I'll close the curtain, and perhaps you can rest. I'll be quiet when I check on you in a few minutes." A client reports a lot of gas in the colostomy bag. Which instruction is best to give this client? Correct response: • Burp the bag. A 6-year-old child is diagnosed with diabetes and requires education along with the family. Which factor is considered when the nurse assists in the planning of the education? Correct response: • The child and parents should be educated together. A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? Correct response: • Risk for aspiration related to general anesthesia 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? Correct response: • Deficient fluid volume related to nausea and vomiting A client is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time? Correct response: • Ineffective peripheral tissue perfusion related to venous congestion A client receives morphine 4 mg intravenous (I.V.) for relief of surgical pain. Thirty minutes later, as part of which step of the nursing process, the nurse asks the client to rate his level of pain using a pain scale? Correct response: • Evaluation While assessing a home care client, the nurse notices a family member smoking near the client's oxygen. Which action by the nurse is best? Correct response: • Explaining to the family member that oxygen is flammable and smoking must be avoided While driving home from work, a nurse realizes that she failed to communicate to the oncoming nurse that a client asked for more information about advance directives. Which action would be appropriate for the nurse to take? Correct response: • Phone the nurse caring for the client and inform her of the client's request. The nurse is assigned to care for a group of clients on the medical-surgical unit. Following report, which client should the nurse see first? Correct response: • a client that a family member states is having a new onset of slurred speech and left facial drooping A client who is a member of the Jehovah’s Witnesses refuses a blood transfusion based on religious beliefs and practices. Which ethical principle is the nurse following when honoring this client’s wishes? Correct response: • the right to refuse treatment A nurse works with a colleague who consistently fails to use standard precautions or wear gloves when caring for clients. The nurse calls these oversights to the colleague's attention, but the colleague claims that standard precautions and gloves are unnecessary unless the client is known to have tested positive for the human immunodeficiency virus. Which action would be most appropriate for the nurse to take? Correct response: • Document the problem in writing for the nurse manager. A nurse is about to give a full-term neonate their first bath. What intervention should the nurse perform first? Correct response: • Check the neonate's temperature. A client undergoing prenatal blood testing is found to be positive for human immunodeficiency virus (HIV). Which action would be most appropriate for the nurse to do? Correct response: • Follow facility policy for documenting and communicating HIV status. A nurse is caring for a bedridden older adult client. Which nursing intervention should the nurse include in this client’s care? Correct response: • Post an every 2 hour turn schedule at the bedside. A client is to be discharged from an acute care facility following 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? Correct response: • evaluation An older adult client admitted to the hospital with an exacerbation of heart failure is confused, has inadvertently pulled out the IV catheter, and is attempting to get out of bed. The health care provider orders the use of physical restraints. Which nursing action reflects safe nursing care? Correct response: • Tie the restraints to the bed frame using a quick-release knot. A client newly diagnosed with type 2 diabetes is admitted to the metabolic unit for treatment initiation and education. Which information should the nurse reinforce to this client as a goal for treatment? Correct response: • exercise and a weight-reduction diet A nurse is caring for several clients. Which client is at greatest risk for aspiration? Correct response: • a client that had a stroke with dysarthria A nurse is planning care for a client after a tracheotomy. One of the client's goals is to overcome verbal communication impairment. Which nursing intervention should the nurse include when assisting with development of the care plan? Correct response: • Encourage the client to communicate by allowing time to write words. A nurse is caring for a client admitted with retinal detachment in the left eye. Which symptom would the nurse expect the client to report during the evaluation? Correct response: • flashing lights in the visual field A nurse is assisting with planning care for a client with retinal detachment. The client has both eyes patched but is alert and oriented. What measure should the nurse include in the care plan to promote safety? Correct response: • Place the call bell within the client's reach and ensure the client knows how to use it. A licensed practical nurse (LPN) is caring for a client who has been on bed rest for several weeks and has a condom catheter in place. During early morning rounds, the nurse notes cloudy urine with sediment, a temperature of 101° F (38.3° C), and hematuria. What should the nurse do next? Correct response: • Consult with the registered nurse (RN) about these findings. The nurse is revising a client's plan of care. Revision of the care plan takes place in which step of the nursing process? Correct response: • Evaluation 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? Correct response: • Evaluation When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be: Correct response: • administering pain medication. A client who underwent surgical repair of a herniated lumbar disk has a physician's order to ambulate during the immediate postoperative period. The client states that he has numbness, weakness, and pain in his leg. How should the nurse intervene? Correct response: • Notify the physician of the client's concerns. The nurse on a neurovascular unit is caring for a client with a head injury. When obtaining vital signs the nurse documents a BP of 180/62 mm Hg and heart rate of 48 beats/min. What intervention by the nurse is essential at this time? Correct response: • Notify the health care provider. An older adult client has been admitted to the medical-surgical unit after surgery. While the nurse is off the floor, the client falls out of bed, resulting in a fracture of the right leg. The nurse finding the client states that the “side rails were left down and the bed was in the high position.” Which charge is most appropriate for the nurse’s actions? Correct response: • negligence A client who is dissatisfied with the current hospitalization decides to leave against medical advice (AMA) and refuses to sign the paperwork. Which action by the nurse would be most appropriate? Correct response: • Allow the client to leave after providing information about the possible consequences of leaving. A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. Which information should be provided to the school? Correct response: • This is an appropriate request and arrangements will be made as soon as possible. A 15-year-old comes to the clinic requesting a test for human immunodeficiency virus (HIV) exposure. The adolescent is concerned that the parents might be notified of the test results. Which response by the nurse is most appropriate? Correct response: • "HIV testing is confidential; after we get the test results, we will discuss your options with you only." A client in her second trimester tells the nurse that she feels very anxious because she is not sure of what will happen when she goes into labor to give birth. Which intervention by the nurse would be most appropriate for this client? Correct response: • Help her enroll in birth preparation classes at the facility where she plans to give birth. A client undergoing a brain computed tomography (CT) scan because of continual migraine headaches is placed in the CT scanner and suddenly reports having palpitations, shortness of breath and shaking. What is the client most liekly experiencing? Correct response: • Panic attack A client who has experienced a stroke is unable to move without help. Which intervention should the nurse perform to reduce this client’s risk for developing a common complication of immobility? Correct response: • Change the client’s position every 1 to 2 hours. A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which homecare instruction should the nurse reinforce? Correct response: • "Monitor your temperature for signs of infection.” A nurse is caring for a client who is receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? Correct response: • Monitor level of consciousness and observe skin color. A parent is preparing for the imminent death of a child due to sickle cell anemia. The parent has been unable to eat or sleep and talks only about the impending loss and feelings of guilt for the child's pain and suffering. Which nursing intervention has the highest priority? Correct response: • Allow the parent to express feelings without judgement. An elderly client asks a nurse how to treat chronic constipation. What is the best recommendation the nurse can make? Correct response: • "Take a stool softener, such as docusate sodium (Colace), daily." A nurse is reinforcing preoperative instructions for a client scheduled for an appendectomy. Which statement regarding postoperative pain control is most appropriate? Correct response: • "To manage your pain well you should take the pain medication before pain becomes intense." An older adult client with pneumonia is having difficulty managing respiratory secretions and clearing the airways. Which nursing intervention would be most appropriate? Correct response: • Monitor the need for suctioning every hour. A client with advanced cancer has been receiving chemotherapy and is experiencing stomatitis. To promote comfort and nutrition while the client's mouth is sore, what should the nurse plan to speak with the client's family about? Correct response: • Rinsing the client's mouth with diluted hydrogen peroxide every 2 hours Which task can a licensed practical nurse (LPN) safely delegate to unlicensed assistive personnel (UAP)? Correct response: • turning a client every 2 hours The nurse is formulating a nursing diagnosis for a mitted client. Which approved nursing diagnosis would the nurse use? Correct response: • Impaired gas exchange After a stroke, a client develops aphasia. The nurse expects to observe which data collection finding in this client? Correct response: • Inability to speak clearly A client admitted with a high fever mentions that his mouth is very dry. Scheduled diagnostic testing restricts him from consuming anything by mouth. Which action by the nurse is best? Correct response: • Performing mouth care The nurse obtains laboratory results on assigned clients during morning report. Which results needs to be immediately reported to the health care provider? Correct response: • potassium level 6.2 mg/dL The client refused an injection, but the nurse administered it anyway. The client wants to sue the nurse. The attorney informs the client that this lawsuit must be filed within two years. What is this time frame called? Correct response: • statute of limitation A licensed practical nurse (LPN) receives a report on several assigned clients at the beginning of the evening shift. The nurse would plan to collect data on which client first? Correct response: • an older adult client with bacterial pneumonia experiencing periods of confusion A nurse is providing care for a pregnant client in her second trimester. A 1-hour oral glucose tolerance test results show that the client has a blood glucose level of 160 mg/dL. Which intervention would the nurse anticipate as being included in the client’s multidisciplinary plan of care? Correct response: • dietary management A client in active labor is having difficulty remaining focused. Her husband, sister, and mother are in the room with her. The fetal monitor shows slowing of the fetal heart rate (FHR) that begins after the peak of each contraction. What is the priority nursing action? Correct response: • Have the client lie on her left side while asking a family member to be with the client one at a time. A nurse is providing care for a client who underwent a mitral valve replacement. Which finding indicates to the nurse that the client is making progress toward a priority goal of treatment by the time of discharge? Correct response: • ambulating from the room door to the end of the hall and back A nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. What is the priority action by the nurse? Correct response: • Notify the healthcare provider. A nurse is caring for an older adult client who is confused. Which nursing intervention can best help to prevent this client from falling? Correct response: • Place the client in an area where regular or continual monitoring is possible. A newly hired licensed practical nurse (LPN) is establishing priorities for morning client evaluations with the assistance of a preceptor. Which client should the nurses evaluate first? Correct response: • a newly admitted client with acute abdominal pain A client receiving hemodialysis treatments has had surgery to form an arteriovenous fistula. Which nursing consideration is most important for the nurse to be aware of when providing care for this client? Correct response: • Taking a blood pressure reading on the affected arm can cause clotting of the fistula. A client with a history of heart failure is admitted to the telemetry unit. Which parameter should the nurse closely monitor in evaluating the client's response to a bolus dose of IV furosemide? Correct response: • hourly intake and output A nurse is assigned to care for a client in the immediate postoperative recovery phase. Which data collection takes priority during the initial assessment? Correct response: • airway, respiratory rate and depth, other vital signs, and skin color A client with a history of duodenal ulcers states to the nurse, “I take antacids once in a while to relieve the pain.” Which statement by the client should be reported immediately? Correct response: • "My bowel movements have been sticky and black." Family members of a client report to the nurse that they are exhausted and it is difficult taking care of a dependent family member. Which approach by the nurse is in the client’s best interest? Correct response: • Call a family conference and ask social services for assistance. A nurse is caring for a client recently diagnosed with acute pancreatitis. Which statement indicates that a short-term goal of nursing care has been met? Correct response: • The client denies abdominal pain. A client presents to the medical clinic for evaluation of a rash and throat tightness. The client reports that the symptoms developed 24 hours after eating peanuts. Which question should the nurse ask the client? Correct response: • “Do you have injectable epinephrine available to carry with you at all times?” While caring for a client with chronic obstructive pulmonary disease (COPD), a licensed practical nurse observes and reports that the client is short of breath, restless, irritable, and disoriented. After nursing interventions f