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Terms in this set (31)
ch14//The home health nurse must devise a way to administer IV antibiotics to a client who insists on being outside during the infusion. Using creativity and critical thinking, the nurse is able to meet the client's requests. This is an example of which of the following?
4. Cognitive skill
The student nurse must accurately perform a sterile dressing change before completing a unit of the course. This student is being evaluated on which of the following?
1. Technical skill
A nurse works in an acute psychiatric setting and sees clients as they are admitted for inpatient psychiatric care. Many of the clients exhibit paranoid behavior. The most important skill this nurse can utilize for these clients is which of the following?
2. Interpersonal skill
During the process of implementing cares and treatments for a client, the nurse realizes there are several entities included in this phase. (Select all that apply):
1. Evaluating the outcome of the interventions
2. Reassessing the client
3. Documenting the history and physical
4. Supervising delegated care
5. Implementing the nursing interventions
Correct Answer: 2,4,5
Upon entering the room, the client is found crying along with the client's spouse. The nurse decides to sit with both of them, offering presence and listening to their fears instead of the planned education. This is an example of which of the following?
4. Reassessing the client
An action that allows new parents to feel in control when being taught how to bath their infants would be when the nurse:
3. Lets the parents bathe the baby with direction and guidance from the nurse.
. The nurse makes sure that the client learning how to administer insulin understands how to activate the safety mechanism on the syringe to prevent needlestick injuries. This is an example of which of the guidelines for implementing interventions?
4. Implement safe care.
On one of the first days working alone, the novice nurse must provide teaching on tracheostomy care to the client as well as the client's spouse. This nurse is not familiar with the teaching aspect. The best action for the nurse is to:
1. Ask the nurse mentor to assist with the teaching after reviewing the procedure.
One of the clients assigned to the nurse's care is to receive a medication that the nurse is not familiar with and is not listed in the drug reference manual. The best action of the nurse is to:
2. Call the pharmacy and do further investigating before administering the medication.
The nurse understands that respect for the dignity of the client is extremely important in providing nursing care. Which of the following is an example of this aspect?
1. Allowing clients to complete their own hygienic cares when possible
A nurse has provided routine morning cares to a client, including all the medications and scheduled treatments. The most appropriate action after this is completed is for the nurse to:
3. Document all cares in the progress notes.
After implementing interventions and reassessing the client's response, the nurse completes the process by evaluating. Evaluation includes which of the following? (Select all that apply.)
1. Purposeful activity
2. Nursing accountability
Correct Answer: 1,2,3,4
In order to differentiate between evaluation and assessment, the student should remember that:
4. The difference is in how the data are used.
A client had an outcome goal stated as follows: Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic. Which statement by the client will the nurse use to evaluate this goal?
2. "My pain is a 4."
The goal statement for a client's care plan read as follows: Client will be able to state two positive aspects of rehab therapy by the end of the week. Which of the following is an appropriately written evaluation statement?
3. Goal met, client able to state two positive aspects of therapy by week's end.
The written goal statement in a client's care plan is: Client will have clear lung sounds bilaterally within 3 days. One of the interventions to meet this goal is that the nurse will teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the client's lungs are indeed clear. In order to relate the intervention to the outcome, the nurse should:
1. Ask how many times per day the client practiced the coughing and deep breathing exercises.
A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. The nurse should:
2. Document that the problem has been resolved and discontinue the care for the problem.
A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan?
3. The goal is unrealistic.
A teenage client has been having problems with peer support, school performance, and parental expectations, all of which have led to an eating disorder. After gathering this assessment data, the nurse formulate the diagnosis Activity Intolerance related to weakness. After evaluating this information, the nurse should realize which of the following?
4. The data are not sufficient enough to support this diagnosis.
A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this client is not to sustain any injuries for the next month. The client however, has fallen several times. In this situation, the nurse should do which of the following?
2. Investigate whether the best nursing interventions were selected.
A nurse manager has been charged with implementing a quality assurance program at the hospital. Quality assurance requires evaluation of several components of care. Select those that apply:
Correct Answer: 2,4,5
A nursing unit has been short staffed for the past month with a heavy client load and high acuity. The nurses on this unit have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned, returned, and stored in the appropriate areas. This unit should be evaluated at which level?
A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. The quality assurance officer is evaluating this unit, paying particular attention to which of the components of care?
A nursing unit's records of client care have been reviewed for accuracy in documentation. This type of review is which of the following?
1. Nursing audit
A nurse has taken a position with an insurance company to review clients' records and the care they received while they were inpatient status. Part of the job description requires the nurse to make sure the client (and insurance company) were billed for services and treatment/therapies rendered and that there were no errors in billing. This type of audit is which of the following?
A nurse is working on a medical unit and assigns a nurse's aide to take vital signs for several clients. The aide completes this task and documents them accordingly. One of the clients had a blood pressure reading of 180/110, and it wasn't until the end of the shift that the nurse realized this value. The physician was notified and orders were received for treatment, but not until much later in the shift. Which of the two responsibilities of delegation did the nurse fail to carry out?
Correct Answer: adequate supervision
A nurse is working on a medical unit, and assigns a nurse's aide to take vital signs for several clients. The aide completes this task and documents them accordingly. One of the clients had a blood pressure reading of 180/110, and it wasn't until the end of the shift that the nurse was apprised of this value. The physician was notified, and orders were received for treatment, but not until much later in the shift. Which responsibility of delegation did the nurse fail to carry out?
4. Appropriately supervising care.
During the process of implementing care and treatments for a client, the nurse realizes there are several entities included in which phase?Select all that apply.
1. Evaluating the outcome of the interventions.
2. Reassessing the client.
3. Documenting the history and physical.
4. Supervising delegated care.
5. Implementing the nursing intervention.
Correct Answer: 2,4,5
After implementing interventions and reassessing the client's response, the nurse completes the process by evaluating. Evaluation includes which of the following attributes?Select all that apply.
1. Purposeful activity.
2. Nursing accountability.
Correct Answer: 1,2,3,4
The nurse shows an understanding of the relationship of evaluation to the other phases of the nursing process when:: Select all that apply.
1. Being careful to effectively assess the client's needs.
2. Selecting the appropriate nursing diagnosis related to the client's needs.
3. Collecting client-focused data with a specific need in mind.
4. Evaluating by using assessment data to determine effective achievement of goals and outcomes.
Correct Answer: 1,2,3,4
When assessment data show a change in the client's condition, the nurse—before changing the care plan—asks: Select all that apply.1. How difficult will it be to change the care plan?
2. Are the new data complete?
3. Are the new data accurate?
4. Do the new data require a change in the care plan?
5. Will the primary medical provider agree with the need to alter the care plan?
Correct Answer: 2,3,4
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