Exam 2: NUR109/ NUR 109 (Latest 2025/2026 Update) Foundations in Nursing Practice | Questions with Verified Answers & Rationale | 100% Correct - Excelsior University.

Exam 2: NUR109/ NUR 109 (Latest
2025/2026 Update) Foundations in
Nursing Practice | Questions with
Verified Answers & Rationale |
100% Correct - Excelsior University.

A nurse has created a plan of care that involves assisting a client
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with ambulation. She attempts to get the client out of bed, but
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the client is obese and unable to move without pain. What action
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should the nurse take?
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1. Change the outcome goals.
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2. Document the attempt to ambulate the client.
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3. Request assistance with ambulating the client.
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4. Amend the nursing diagnosis and interventions.
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Request assistance with ambulating the client.*
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Rationales
Option 1: i,-

,The outcome goals should not be changed because a particular
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intervention is difficult. i,- i,-




Option 2: i,-




All nursing care should be documented, but this is not the only
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action that should be taken after a failed attempt to ambulate a
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client.
Option 3: i,-




The nurse should obtain the necessary assistance to ambulate the
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client, and make every effort to meet the outcome goals.
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Option 4: i,-




The nursing diagnosis and interventions should not be changed
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because a certain implementation is difficult. The nurse should
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gather needed resources. i,- i,-




A client is admitted for a hip fracture following a fall at home. The
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client has surgery to repair the fracture and is getting ready for
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discharge. The client is using a walker to ambulate and working
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with physical therapy. Which is an important consideration for
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this client for discharge planning?
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1. Ability to pay for continued physical therapy
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2. Community resources available
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3. The safety and physical layout of the home environment
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,4. Compliance with follow-up appointments
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and physical layout of the home environment*
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Rationales
Option 1: i,-




Ability to pay is not part of the discharge care plan. The individual
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needs should be considered, including cost-effectiveness.
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Option 2: i,-




Community resources may be considered for this client, but this is
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not an important consideration as part of discharge care planning.
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Option 3: i,-




The ability of the client to live and function in his or her own
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home is a very important consideration. If the client is using a
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walker, and the home has stairs or narrow hallways, this should
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be considered prior to discharge.
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Option 4: i,-




Compliance with follow-up appointments is important in i,- i,- i,- i,- i,- i,- i,-



planning discharge care, but this is not the priority to consider in
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this instance.
i,-




Which is a valid goal statement for measuring and managing
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pain?

, 1. The client will not complain of pain.
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2. The nurse will administer pain medication as ordered.
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3. The client will have minimal pain.
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4. The client will report pain greater than level 4 to the nurse.
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*4. The client will report pain greater than level 4 to the nurse.*
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Rationales
Option 1: i,-




A vague statement that includes the client not verbalizing pain is
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not a valid measurement of a goal.
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Option 2: i,-




A goal statement includes the desired outcomes, not the action
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of the nurse.
i,- i,-




Option 3: i,-




Minimal pain is too vague a goal statement, as it is not
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measurable or valid. i,- i,-




Option 4: i,-




The client reporting pain greater than a specific level is a valid,
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measurable goal. i,-




A nurse has just completed inventory on the controlled
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substances on the unit, has completed necessary documentation,
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and locked the cabinet. He or she walks away, leaving the locked
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