Chp 44
The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the client's legs when turning? Select all that apply.
1. Stabilizes the spine
2. Prevents hip contractures
3. Supports the upper leg
4. Keeps the legs parallel and aligned
5. Prevents adduction of the upper leg
Answer: 3, 4, 5
Explanation: 3. A pillow between the client's legs when logrolling supports the upper leg when the client is turned.
4. A pillow between the client's legs when logrolling keeps the legs parallel and aligned.
5. A pillow between the client's legs when logrolling prevents adduction of the upper leg.
Page Ref: 1042
The student is learning the steps of the nursing process. What is the first thing that the student should realize about the purpose of this process?
1. Deliver care to a client in an organized way.
2. Implement a plan that is close to the medical model.
3. Identify client needs and deliver care to meet those needs.
4. Make sure that standardized care is available to clients.
Answer: 3
Explanation: 3. The purpose of the nursing process is to identify a client's health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs.
Page Ref: 155
room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 5 is least priority).
1. The family is at the bedside.
2. The IV pump is running on battery.
3. The ECG monitor shows tachycardia.
4. The client reports being restless.
5. O2 tubing is not attached to wall regulator.
Answer: 3, 4, 5, 2, 1
Explanation: 1. Has no apparent bearing on client's symptoms
2. Indicates an issue worth observing
3. Indicates an objective cardiac symptom
4. Indicates a subjective symptom
5. Indicates a possible cause of the client's symptoms
Page Ref: 164
A nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension. What did the nurse implement in this situation?
1. A STAT order
2. A one-time order
3. A prn order
4. A standing order
Answer: 4
Explanation: 4. Standing orders are a written document about policies, rules, regulations, or orders regarding client care.
Page Ref: 191
On one of the first days working alone, the new nurse with limited patient teaching experience needs to instruct tracheostomy care to a client and spouse. What action should the nurse take?
1. Ask the nurse mentor to assist with the teaching after reviewing the procedure.
2. Read the policy and procedure manual before the teaching session.
3. Do the best the nurse can by remembering what was taught in nursing school.
4. Ask for a different assignment until the nurse feels comfortable with this one.
Answer: 1
Explanation: 1. When implementing some nursing interventions, the nurse may require assistance. In this case, the nurse lacks the knowledge or skills to implement a particular nursing activity (teaching).
Page Ref: 210
The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment?
1. Decrease in blood pressure when moving from supine to standing
2. Decrease in heart rate when moving from supine to sitting
3. Pale color in the legs when lying in bed
4. Complaints of dizziness when first sitting up
Answer: 1
Explanation: 1. Orthostatic hypotension occurs when the normal vasoconstriction reflex in the legs is dormant and the client's central blood pressure drops when moving from supine to sitting or to standing.
Page Ref: 1054
While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Answer: 1
Explanation: 1. Assessment is the collection, organization, validation, and documentation of data. Assessment is carried throughout the nursing process, as in this case. Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment.
Page Ref: 159
The nurse is preparing to write nursing diagnoses for a client. What should the nurse recall about the NANDA label?
1. Must contain three components
2. Describes the health problem for which nursing therapy is given
3. Helps define medical diagnoses for nursing
4. Promotes a taxonomy of nursing
Answer: 4
Explanation: 4. The purpose of the NANDA label is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. This label describes the health problem or response by the client for which nursing therapy is given.
Page Ref: 176
A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately?
1. Client will ambulate without a walker by 6 weeks.
2. Client will ambulate freely in house.
3. Client will not fall.
4. Client will have freer movement in daily activities.
Answer: 1
Explanation: 1. Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulating without a walker by a certain date is specific as well as measurable.
Page Ref: 197
A client is prescribed a medication that the nurse has never administered and information about the medication is not in the drug reference manual. What should the nurse do?
1. Follow the physician's orders as written and give the medication.
2. Call the pharmacy and do further investigating before administering the medication.
3. Ask the client about this medication.
4. Call the physician and ask what the medication is and what it is for.
Answer: 2
Explanation: 2. The nurse should clearly understand all nursing interventions to be implemented and question any that are not understood. The nurse is responsible for intelligent implementation of medical and surgical plans of care. The pharmacist would be the most appropriate reference point for this nurse to begin to research this problem.
Page Ref: 210
The client who is unconscious is developing foot drop. What nursing action is indicated?
1. Place high-topped shoes on the client while in bed.
2. Keep the linens on the end of the bed turned back to expose the feet.
3. Use only the prone and Sims positions for client positioning.
4. Use a device to elevate the linens off the feet.
Answer: 1
Explanation: 1. High-topped shoes will place the client's feet in the anatomical position of dorsal flexion.
Page Ref: 1035
During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says "leave me alone." Which subjective data should the nurse document?
1. Restlessness
2. "Leave me alone"
3. Not talkative
4. Pale and diaphoretic
Answer: 2
Explanation: 2. Subjective data can be described or verified only by that person and are apparent only to the person affected. Subjective data include the client's sensations, feelings, beliefs, attitudes, and perceptions of personal health status and life situations.
Page Ref: 160
The nurse selects the nursing diagnosis of Enhanced readiness for spiritual well-being for a family. Which data cluster did the nurse use to support this diagnosis?
1. The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends' families.
2. The children attend Sunday school classes, one parent always attends services with the children, and the parents attempt interaction with congregational activities.
3. The grandparents go to weekly services and have formal interaction with clergy.
4. The children have attended private, religious schools, and the parents are involved in the school's activities.
Answer: 1
Explanation: 1. A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. The data cluster that describes the questioning, searching, and reflecting would support an attitude of readiness.
Page Ref: 176
The nurse identifies for a client the nursing diagnosis "Fluid volume deficit, related to active fluid loss, secondary to diarrhea." What would be and appropriate goal statement for this diagnosis?
1. Client will drink more fluids by tomorrow.
2. Client will have good skin turgor.
3. Client will have moist mucous membranes.
4. Client will have intake of at least 1000 mL within 24 hours.
Answer: 4
Explanation: 4. The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress, and all options must have a time frame for evaluating the desired performance. This option includes all necessary components.
Page Ref: 197
The nurse is reviewing the difference between evaluation and assessment with a new graduate nurse. What should the nurse emphasize as the major difference between these two steps in the nursing process?
1. Assessment is done at the beginning of the process.
2. Evaluation is completed at the end of the process.
3. They are the same and there is no need to differentiate.
4. The difference is in how the data are used.
Answer: 4
Explanation: 4. Although the two processes overlap, there is a difference between the data collected. Assessment data are collected for the nurse to make a diagnosis and evaluate desired outcomes. Evaluation data are collected for the purpose of comparing them to prescribed goals and judging the effectiveness of the nursing care.
Page Ref: 211
The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? Select all that apply.
1. Place a turn sheet on the bed.
2. Always use two personnel to move the client.
3. Stand at the head of the bed to pull the client up.
4. Slide the client toward the head of the bed.
5. Encourage the client to assist as possible.
Answer: 1, 2, 5
Explanation: 1. Placing a turn sheet on the bed will help overcome inertia and friction during moving.
2. Using two personnel will allow a "lift and move" rather than pulling or sliding the client over linens.
5. Encouraging the client to assist as much as possible will lighten the workload.
Page Ref: 1035
Family of a client demonstrating confusion state that this is not the client's usual behavior. How should the nurse document this data?
1. Inference
2. Subjective data
3. Objective data
4. Secondary subjective data
Answer: 3
Explanation: 3. Information supplied by family members, significant others, or other health professionals are considered subjective if it is not based on fact. Because this information is factual, in that the spouse is able to provide the nurse with information about the client's routine behavior and patterns, this is objective data.
Page Ref: 160
A client has been having pain without any clear pathology for cause. Which nursing diagnosis should the nurse identify as being the most appropriate for this client?
1. Pain due to unknown factors
2. Pain related to unknown etiology
3. Pain caused by psychosomatic condition
4. Pain manifested by client's report
Answer: 2
Explanation: 2. The second part of the nursing diagnosis statement is the etiology (E)—the factors contributing to or probable causes–and should be joined to the first part, the problem (P), by the words "related to" rather than "due to." The phrase "related to" implies a relationship between the problem and the cause. In this situation, the cause is unknown, but the problem is evident.
Page Ref: 182
The nurse is reviewing interventions written for a client's plan of care. Which intervention should the nurse recognize as being dependent?
1. Repositioning the client every 2 hours
2. Assisting the client with transfers to the bathroom
3. Providing ongoing physical assessment, especially of the incisional sites
4. Administering medications for pain
Answer: 4
Explanation: 4. Dependent interventions are those activities carried out under the physician's orders or supervision or according to specified routines. The nurse is responsible for assessing the need for and administering medications, but the physician prescribes them.
Page Ref: 201
The nurse notes that a client has the outcome goal "Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic." Which client statement should the nurse use to evaluate this goal?
1. "I'm getting really sleepy from that medication. I think I'll take a nap."
2. "My pain is a 4."
3. "I still have some pain."
4. "Will the pain ever go away?"
Answer: 2
Explanation: 2. The nurse collects data so that conclusions can be drawn about whether goals have been met. If the goal is clearly stated, precise, and measurable, it will be easy to evaluate. If the goal was a pain level of 3, the client should be able to give a numerical rating to the pain in order for the nurse to evaluate it.
Page Ref: 211
When planning care, the nurse should identify which client as needing logrolling for position changes?
1. A client with documented pneumonia
2. The client who has had abdominal surgery
3. The client who fell from a house, sustaining a fractured tibia
4. A client who has a severe headache from hypertensive crisis
Answer: 3
Explanation: 3. The logrolling technique is used in moving any client who may have sustained a spinal injury. Of these clients, the most concern is for the client who fell from a house.
Page Ref: 1042
The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse implementing?
1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation
Answer: 3
Explanation: 3. Implementation is that part of the nursing process in which the nurse applies knowledge to perform interventions.
Page Ref: 159
A client is diagnosed with pneumonia and has been hospitalized for several days. Which nursing diagnosis should the nurse identify as a priority for this client?
1. Altered oral mucous membranes, related to dry mouth
2. Activity intolerance, related to oxygen supply imbalance
3. Knowledge deficit, related to medication regimen
4. Ineffective airway clearance, related to increased secretions
Answer: 4
Explanation: 4. Prioritizing care must begin with the basic needs, in this case, the airway.
Page Ref: 185
The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention?
1. Assist client with ambulation.
2. Ambulate with client, using a gait belt, twice daily for 15 minutes.
3. Make sure client understands the rationale for using the gait belt.
4. Client will ambulate in hallway twice daily.
Answer: 2
Explanation: 2. A well-written intervention should include a verb, conditions, and modifiers, plus a time element. Identifying what to do (ambulate), how to do it (with a gait belt), and how long (twice daily for 15 minutes) is the most precise statement.
Page Ref: 201
A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." What statement demonstrates that the nurse appropriately evaluated this goal?
1. Goal not met, client able to state one positive aspect by the end of the week.
2. Goal met, client able to state one positive aspect by the end of the week.
3. Goal met, client able to state two positive aspects of therapy by week's end.
4. Goal incomplete, client not able to positively state anything about rehab.
Answer: 3
Explanation: 3. An evaluation statement consists of two parts: a conclusion and supporting data. The conclusion is a statement that the goal/desired outcome was met, partially met, or not met. The supporting data are the list of the client responses that support the conclusion. In this situation, the goal was met if the client was able to state two positive aspects of rehab by the end of the week, and the evaluation statement should reveal that.
Page Ref: 211