The Nursing Process
Which finding is an example of a variance in the critical pathway of a client 3 days after
an above-the-knee amputation? - ANS Temperature of 102° F (38.9°C)
The nurse creates a program to decrease the primary cause of disability and death in
children. What is the most important action to include in the plan? - ANS Teach health
and safety practices to children and their parents.
The nurse manager has assigned a nurse as the circulating nurse for a surgical
abortion. The nurse has a religious objection and wishes to refuse to participate in an
abortion. What should the nurse manager of the operating room do? - ANS Change the
assignment without comment.
The nurse is planning a continuous quality improvement (CQI) process to decrease the
infection rate on the nursing unit. The nurse should consider which factors when
planning the process? Select all that apply. - ANS CQI processes are required by
accrediting agencies.
The approach to CQI can be retrospective or concurrent.
The charge nurse on a hematology/oncology unit is reviewing the policy for using
abbreviations with the staff. The charge nurse should emphasize which information
about why dangerous abbreviations need to be eliminated? Select all that apply. - ANS
to ensure efficient and accurate communication
to prevent medication errors
to ensure client safety
A client who just underwent a mastectomy is due to arrive at the post-surgical care unit.
Which actions should the nurse prioritize when attempting to establish an effective
relationship with the client? - ANS Recognize and address the client's anxiety.
Which documentation would indicate nursing actions were effective in reducing
breathing problems for a client? Select all that apply. - ANS anxiety decreased, oxygen
saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min
lung sounds clear bilaterally with non-labored respirations noted
,A nurse is admitting a client to the palliative unit and discussing advanced directives.
Which of the following statements made by the client leads the nurse to believe the
client requires clarification around advanced directives? - ANS "This will stop my
daughter-in-law from putting me in a home."
A nurse wants to ensure inclusiveness in language regarding family when developing a
plan of care for a client. Which action is the most important for the nurse to take to
ensure that the plan is inclusive? - ANS Ask the client to identify who is considered
family.
The nurse assists the client to the operating room table and supervises the operating
room technician preparing the sterile field. Which action, completed by the surgical
technician, indicates to the nurse that a sterile field has been contaminated? - ANS
Wetness in the sterile cloth on top of the nonsterile table has been noted.
Which intervention is an example of primary prevention? - ANS administering a
measles, mumps, and rubella immunization to an infant
A nurse on the mental health unit tells the nurse manager, "Kids with conduct disorders
might as well be jailed because they all end up as adults with antisocial personality
disorder anyway." What is the best reply by the nurse manager? - ANS "You sound
really frustrated. Let's talk about the meaning of their behavior."
Under which circumstance may a nurse communicate medical information without the
client's consent? - ANS when treating the client with a sexually transmitted disease
A nurse has made a medication error. Which information is appropriate to include in the
incident report? - ANS what the nurse saw and did
After the surgeon's meeting with a client to obtain the client's informed consent for a
modified radical mastectomy, the client asks the nurse many questions about breast
reconstruction that the nurse finds difficult to answer. The nurse should: - ANS Inform
the surgeon that the client has questions about reconstruction before she signs the
consent.
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? - ANS excess fluid volume
, A client has received numerous different antibiotics and now is experiencing diarrhea.
What type of precautions should the nurse institute? - ANS contact precautions
A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding
order in the client's chart should be written as - ANS moxifloxacin 400 mg daily
A home care nurse is caring for a paralyzed client who needs regular position changes
and back massages. A person identifying themself as a family friend inquires if they can
be of any help to the family. What should be the nurse's response be? - ANS The nurse
should ask the person to talk to the family directly.
A nurse who works on a palliative care unit has participated in several clinical scenarios
that have required the application of ethics. Ethics is best defined as - ANS the
principles that determine whether an act is right or wrong
A mentally incapacitated client is scheduled for surgery. Considering the principle of
autonomy, who should give the consent for surgery? - ANS surrogate decision maker
In preparation for discharge, the nurse is reviewing information related to new dietary
guidelines with the client. This is an example of which step in discharge planning? -
ANS providing client teaching
A client in a long-term care facility signed a form requesting not to be resuscitated. The
client develops pneumonia, and the client's health rapidly deteriorates. The client is no
longer competent, but the family wants everything possible done for the client. When
the family asks the nurse what will be done, what is the best response by the nurse? -
ANS "We will continue to use antibiotics to treat the pneumonia."
A public health nurse is responsible for contact tracing of individuals identified in
confirmed cases of sexually transmitted infections. The nurse telephones an individual
named by a client as a contact. The individual demands the name of the person who
identified the individual as a contact. Which of the following is the most appropriate
response from the nurse? - ANS "Just as I will protect your privacy, I must protect the
privacy of the other people involved."
A nurse is caring for a client who speaks only French. The client's grandchild is bilingual
and assists with translating, but the nurse needs to provide the client with discharge
instructions. Which of the following would be the best option for the nurse and the
client? - ANS Ask the manager to find an interpreter who is able to provide the
discharge instructions.
Which finding is an example of a variance in the critical pathway of a client 3 days after
an above-the-knee amputation? - ANS Temperature of 102° F (38.9°C)
The nurse creates a program to decrease the primary cause of disability and death in
children. What is the most important action to include in the plan? - ANS Teach health
and safety practices to children and their parents.
The nurse manager has assigned a nurse as the circulating nurse for a surgical
abortion. The nurse has a religious objection and wishes to refuse to participate in an
abortion. What should the nurse manager of the operating room do? - ANS Change the
assignment without comment.
The nurse is planning a continuous quality improvement (CQI) process to decrease the
infection rate on the nursing unit. The nurse should consider which factors when
planning the process? Select all that apply. - ANS CQI processes are required by
accrediting agencies.
The approach to CQI can be retrospective or concurrent.
The charge nurse on a hematology/oncology unit is reviewing the policy for using
abbreviations with the staff. The charge nurse should emphasize which information
about why dangerous abbreviations need to be eliminated? Select all that apply. - ANS
to ensure efficient and accurate communication
to prevent medication errors
to ensure client safety
A client who just underwent a mastectomy is due to arrive at the post-surgical care unit.
Which actions should the nurse prioritize when attempting to establish an effective
relationship with the client? - ANS Recognize and address the client's anxiety.
Which documentation would indicate nursing actions were effective in reducing
breathing problems for a client? Select all that apply. - ANS anxiety decreased, oxygen
saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min
lung sounds clear bilaterally with non-labored respirations noted
,A nurse is admitting a client to the palliative unit and discussing advanced directives.
Which of the following statements made by the client leads the nurse to believe the
client requires clarification around advanced directives? - ANS "This will stop my
daughter-in-law from putting me in a home."
A nurse wants to ensure inclusiveness in language regarding family when developing a
plan of care for a client. Which action is the most important for the nurse to take to
ensure that the plan is inclusive? - ANS Ask the client to identify who is considered
family.
The nurse assists the client to the operating room table and supervises the operating
room technician preparing the sterile field. Which action, completed by the surgical
technician, indicates to the nurse that a sterile field has been contaminated? - ANS
Wetness in the sterile cloth on top of the nonsterile table has been noted.
Which intervention is an example of primary prevention? - ANS administering a
measles, mumps, and rubella immunization to an infant
A nurse on the mental health unit tells the nurse manager, "Kids with conduct disorders
might as well be jailed because they all end up as adults with antisocial personality
disorder anyway." What is the best reply by the nurse manager? - ANS "You sound
really frustrated. Let's talk about the meaning of their behavior."
Under which circumstance may a nurse communicate medical information without the
client's consent? - ANS when treating the client with a sexually transmitted disease
A nurse has made a medication error. Which information is appropriate to include in the
incident report? - ANS what the nurse saw and did
After the surgeon's meeting with a client to obtain the client's informed consent for a
modified radical mastectomy, the client asks the nurse many questions about breast
reconstruction that the nurse finds difficult to answer. The nurse should: - ANS Inform
the surgeon that the client has questions about reconstruction before she signs the
consent.
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? - ANS excess fluid volume
, A client has received numerous different antibiotics and now is experiencing diarrhea.
What type of precautions should the nurse institute? - ANS contact precautions
A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding
order in the client's chart should be written as - ANS moxifloxacin 400 mg daily
A home care nurse is caring for a paralyzed client who needs regular position changes
and back massages. A person identifying themself as a family friend inquires if they can
be of any help to the family. What should be the nurse's response be? - ANS The nurse
should ask the person to talk to the family directly.
A nurse who works on a palliative care unit has participated in several clinical scenarios
that have required the application of ethics. Ethics is best defined as - ANS the
principles that determine whether an act is right or wrong
A mentally incapacitated client is scheduled for surgery. Considering the principle of
autonomy, who should give the consent for surgery? - ANS surrogate decision maker
In preparation for discharge, the nurse is reviewing information related to new dietary
guidelines with the client. This is an example of which step in discharge planning? -
ANS providing client teaching
A client in a long-term care facility signed a form requesting not to be resuscitated. The
client develops pneumonia, and the client's health rapidly deteriorates. The client is no
longer competent, but the family wants everything possible done for the client. When
the family asks the nurse what will be done, what is the best response by the nurse? -
ANS "We will continue to use antibiotics to treat the pneumonia."
A public health nurse is responsible for contact tracing of individuals identified in
confirmed cases of sexually transmitted infections. The nurse telephones an individual
named by a client as a contact. The individual demands the name of the person who
identified the individual as a contact. Which of the following is the most appropriate
response from the nurse? - ANS "Just as I will protect your privacy, I must protect the
privacy of the other people involved."
A nurse is caring for a client who speaks only French. The client's grandchild is bilingual
and assists with translating, but the nurse needs to provide the client with discharge
instructions. Which of the following would be the best option for the nurse and the
client? - ANS Ask the manager to find an interpreter who is able to provide the
discharge instructions.
