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A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation - correct answer A. Assessment Rationale: The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data. Six Competencies of QSEN - correct answer Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data?
A. The client reports abdominal pain B. The client's urine output was 450 mL C. The client states, "I didn't see any stones in my urine." D. The client states, "I feel like I have passed a stone." - correct answer B. The client's urine output was 450 mL. Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse. The objective data is the measurement of the urine output. A client's statements and reports of symptoms are documented as subjective data, such as the data found in options 1, 3, and 4. The Joint Commission - correct answer an independent, not-for-profit organization that evaluates and accredits healthcare organizations Core measures developed to improve the quality of health care by implementing a national, standardized performance measurement system emergency preparedness (internal/external) When evaluating an elderly client's blood pressure (BP) of 146/ mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension?
A. Admitting not knowing how to do a procedure and requesting help B. Using clever and persuasive remarks to support an opinion or position C. Accepting without question the values acquired in nursing school D. Finding a quick and logical answer, even to complex questions E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs. - correct answer A. Admitting not knowing how to do a procedure and requesting help E. Gathering three assistants to transfer the client to a stretcher after noting the client weighs 300 lbs. Rationale: Critical thinking in nursing is self-directed, supporting what nurses know and making clear what they do not know. It is important for nurses to recognize when they lack the knowledge they need to provide safe care for a client (option 1). Nurses must also utilize their resources to acquire the support they need to care for a client safely (option 5). Options 2, 3, and 4 do not demonstrate critical thinking. Nurse's role in the informed consent process is: - correct answer Nurses witness informed consents Ensure provider gave the necessary information Ensure patient is competent and understood Have patient sign the document
Notify the provider if the patient appears not to understand or still has questions The nurse has documented the following outcome goal in the care plan: "The client will transfer from bed to chair with two-person assist." The charge nurse tells the nurse to add which of the following to complete the goal? A. Client behavior B. Conditions or modifiers C. Performance criteria D. Target time - correct answer D. Target time Rationale: The outcome goal does not state the target timeframe for when the nurse should expect to see the client behavior ("transfer"). The condition or modifier is present ("with two assists"). The performance criterion is "from bed to chair." Nurses Role in Advance Directives - correct answer Provide written information about advance directives Document the client's advance directives status Ensure that the advance directives reflect the client's current decisions Inform all members of the health care team of the client's advance directives
established, the interventions are implemented (option 3) and evaluated (option 4). When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? A. Omitting this dose of medication and waiting until the client is more cooperative B. Suggesting the medication can be diluted in a beverage C. Asking the nurse manager about how to approach the situation D. Notifying the physician inability to give the client this medication - correct answer B. Suggesting the medication can be diluted in a beverage Rationale: Diluting the medication in a beverage may make the medication more palatable. Using critical thinking skills, the nurse should try to problem-solve in a situation such as this before asking for the assistance of the nurse manager. Suggesting an alternative method of taking the medication (provided that there are no contraindications to diluting the medication) should improve the likelihood of the client taking the medication. SBAR - correct answer consistent, clear, structured, and easy-to-use method of communication between health care personnel
Situation (your name, where from, pt, room #, why calling) Background (age, PERTINENT info) Assessment (current vitals, assess. findings, what you think problem is) Recommendations (what action? change in treatment? more labs? does provider want a call back with updates?) Which professionally appropriate response should the nurse make when a more stringent policy for the use of restraints is introduced on a surgical unit? A. Use the previous, less restrictive policy conscientiously B. Express immediate disagreement with the new policy C. Ask for the rationale behind the new policy D. Obey the policy but continue to voice disapproval of it to co-workers - correct answer C. Ask for the rationale behind the new policy Rationale: Understanding the rationale behind a decision helps the nurse analyze the proposed change and understand its purpose.
C. Ask whether the UAP has time to assist the client D. Ask the charge nurse whether UAPs have ambulated the client during this shift - correct answer A. Assess the client to be sure ambulation with assistance is an appropriate care measure Rationale: Prior to delegating any client care responsibilities, the nurse must assess the client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4 would not constitute an assessment of the client's current status. While caring for a child, you identify that additional safety teaching is needed when a young and inexperienced mother states that: A. Teenagers need to practice safe sex. B. A 3-year-old can safely sit in the front seat of the car. C. Children need to wear safety equipment when bike riding. D. Children need to learn to swim even if they do not have a pool. - correct answer B. The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the following actions? A. Notify the physician
B. Reassign the client to another nurse C. Reexamine the nursing orders D. Write a new nursing diagnosis - correct answer B. Reexamine the nursing orders Rationale: The plan needs to be reassessed whenever goals are not met. Nursing interventions should be examined to ensure the best interventions were selected to assist the client achieve the goal. The goal may be appropriate, but the client may need more time to achieve the desired outcome. The manner in which the nursing interventions were implemented may have interfered with achieving the outcome. A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include: A. Raise all four side rails when darkness falls. B. Use an electronic bed monitoring device. C. Place the patient in a room close to the nursing station. D. Use a loose-fitting vest-type jacket restraint. - correct answer B. In developing a plan of care for a client with chronic hypertension, which nursing activity would be most important?
Which nurse is demonstrating the assessment phase of the nursing process? A.The nurse who observes that the client's pain was relieved with pain medication B. The nurse who turns the client to a more comfortable position C. The nurse who ask the client how much lunch he or she ate D. The nurse who works with the client to set desired outcome goals - correct answer C. The nurse who ask the client how much lunch he or she ate Rationale: Assessment involves collecting, organizing, validating, and documenting data about a client. Option 1 represents the evaluation phase. Option 2 represents the implemention phase. Option 4 represents the planning phase. adverse events that should never occur in a health care setting - correct answer never event The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A. Subjective data from a primary source B. Subjective data from a secondary source
C. Objective data from a primary source D. Objective data from a secondary source - correct answer A. Subjective data from a primary source Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of which type and source? A nurse discovers an electrical fire in a patient's room. Which action should the nurse take first? Turn off the oxygen to the unit. Evacuate any patients/visitors in immediate danger. Close all doors and windows. Use the nearest fire extinguisher to put the fire out. - correct answer Evacuate any patients/visitors in immediate danger The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10 days (and essentially no protein intake). The nurse would formulate which diagnostic statement that would best reflect this problem? A. Risk for malnutrition related to clear liquid diet B. Impaired skin integrity related to no protein intake
C. Imbalance nutrition: more than body requirement related to overweight status D. Impaired physical mobility related to generalized weakness and pain
- correct answer B. Impaired gas exchange related to aspiration of foreign matter as evidence by oxygen saturation of 91% Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human response) names/labels the problem. The second part (related factors) includes the factors that either contribute to or are probable etiologies of the human response. Some formats include a third part to the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms and is joined to the statement with the label as evidenced by. This type of statement is the most complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague. What is the proper order for applying a wrist restraint?
- Pad the skin overlying the wrist.
- Insert two fingers under secured restraint to be sure that it is not too tight.
- Be sure that patient is comfortable and in correct anatomical alignment.
- Secure restraint straps to bed frame with quick-release buckle.
- Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly. - correct answer 3,1,5,2, Which of the following outcome goals has the nurse designed correctly for the postoperative client's plan of care? Select all that apply. A. Client will state pain is less than or equal to 3 on zero to ten pain scale B. Client will have no pain C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge E. Client will be medicated every 4 hours by the nurse - correct answer C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be pain free. Option 5 is not a client goal.
inappropriate for a client, the nurse must act as a client advocate and collaborate with the appropriate healthcare team member to determine the rationale for the order and/or modify the order as necessary. A nurse accepts accountability for his or her actions. Options 1, 3, and 4 are inappropriate and unsafe. TJC's Speak Up Tips - correct answer -Speak up if you have questions or concerns. -Pay attention to the care you get. -Educate yourself about your illness. -Ask a trusted family member or friend to be your advocate. -Know which medicines you take and why. -Use a health care organization that has been carefully evaluated. -Participate in all decisions about your treatment. Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)? A. Taking vital signs of clients on the nursing unit B. Assisting the physician with an invasive procedure C. Adjusting the rate on an infusion pump D. Evaluating achievement of client outcome goals - correct answer A. Taking vital signs of clients on the nursing unit
Rationale: Part of the professional nurse's role is to delegate responsibility for activities while maintaining accountability. The nurse must match the needs of the client with the skills and knowledge of UAPs. Certain skills and activities, such as those in options 2, 3, and 4, are not within the legal scope of practice for a UAP. Includes all intellectual behaviors and requires thinking - correct answer Cognitive In giving a change-of-shift report, which type of client information communicated by the nurse is most appropriate? A. Vital signs are stable B. Client is pleasant, alert, and oriented to time, place, and person C. The chest x-ray results were negative D. Client voided 250 mL of urine 2 hours after the urinary catheter removal - correct answer D. Client voided 250 mL of urine 2 hours after the urinary catheter removal Rationale: A change-of-shift report should include significant changes (good or bad) in a client's condition. The information should be accurate, concise, clear, and complete. Options 1 is vague and options 2 and 3 are normal data and are therefore of lesser importance to convey in the change-of-shift report.
