with verified answers
a nurse is admitting a client who will undergo a craniotomy. During the
planning phase of the nursing process, which of the following actions should
the nurse take?
a) establish client outcomes
b) collect information about past health problems
c) determine whether the client has met specific goals
d) identify the client's specific health problem ~Correct Answer ~a) establish
client outcomes
The planning phase includes developing goals and outcomes that help the
nurse create the client's plan of care.
The nursing process:
,step 1. assessment phase- collect information about past health problems
(vitals, age, height) step 2. analysis phase- identify the client's
specific health problem
step 3. planning phase- establish client goals and outcomes and selects
interventions that will help to achieve them. Also involves setting care
priorities.
step 4. implementation- provides client care and uses interpersonal/technical
skills when implementing nursing interventions
step 5. evaluation phase- use critical thinking skills to determine whether the
client has met a specific goal. examines results, compares the data, identifies
errors, and considers pt's situation
a client who reports shortness of breath requests the nurse's help in changing
positions. After repositioning the client, which of the following actions should
the nurse take next?
a) encourage the client to take deep breaths
b) observe the client's rate, depth, and character of respirations
c) prepare to administer oxygen
,d) give the client a backrub to promote relaxation ~Correct Answer ~b)
observe the client's rate, depth, and character of respirations
a nurse is collecting health history data from a client who is deaf and uses
American sign language(ASL) to communicate. The nurse will be working
with an ASL interpreter. Which of the following actions should the nurse
take when working with the interpreter?
a) face away from the client to avoid distractions
b) pace speech to allow time for the interpreter to convey the words
c) make eye contact with the interpreter when explaining the procedure
d) stand in the background while the interpreter translates the message
~Correct Answer ~b) pace speech to allow time for the interpreter to
convey the words
a nurse manager is providing teaching to a group of newly licensed nurses
about the ways that clients acquire healthcare-associated-infections (HAI's).
Which of the following routes of infection should the manager identify as an
iatrogenic HAI?
, a) infection required from improper hand hygiene
b) infection acquired by drug resistance
c) infection acquired by inappropriate waste disposal
d) infection acquired from diagnostic procedure ~Correct Answer ~d) infection
acquired from diagnostic procedure
Iatrogenic HAIs directly result from diagnostic or therapeutic procedures
a nurse is caring for a client who has Clostridium difficile infection and is in
contact isolation. Which of the following actions should the nurse take?
a) wear gloves when changing the clients gown
b) use alcohol-based sanitizers to cleanse the hands
c) wear a mask when assisting the client with his meal tray
d) place the client on a complete bed rest ~Correct Answer ~a) wear gloves
when changing the clients gown
-alcohol-based sanitizers are ineffective against the spores of C.difficile