CH 16 PrepU Flashcards
Which is an example of a nurse-initiated intervention?
Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain.
Administer a 1000-mL soap suds enema.
Teach the client how to splint an abdominal incision when coughing and deep breathing.
Administer oxygen at 4 L/min per nasal cannula.
Teach the client how to splint an abdominal incision when coughing and deep breathing.
Which outcome for a client with a new colostomy is written correctly?
The client will know how to care for the stoma by 3/29/20.
The client will demonstrate proper care of the stoma by 3/29/20.
Explain to the client the proper care of the stoma by 3/29/20.
The client will be able to care for stoma and cope with psychological loss by 3/29/20.
The client will demonstrate proper care of the stoma by 3/29/20.
The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?
The nurse has omitted the defining characteristics.
The outcome should indicate what the nurse will do.
The nurse has omitted the time frame.
The nurse has not made any error in writing the outcome.
The nurse has omitted the time frame.
When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:
identifies the unhealthy response preventing desired change.
identifies client strengths.
suggests client goals to promote desired change.
identifies factors causing undesirable response and preventing desired change.
identifies factors causing undesirable response and preventing desired change.
A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?
Consult with another nurse.
Set priorities using client care standards.
Seek research about the disorder.
Follow institutional guidelines.
Seek research about the disorder.
The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. When completing the plan of care, which outcome is written the clearest for working with the multidisciplinary team?
After visiting the clinic, client will indicate a desire for adoption.
By discharge from the fertility clinic, the client will achieve full-term pregnancy.
Client will understand the importance of follow-up laparoscopic examination.
By the next clinic visit, the nurse will discuss the client’s feelings around infertility.
By discharge from the fertility clinic, the client will achieve full-term pregnancy.
The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, “I have smoked since I was 12 years old. I am not going to stop now.” What is the appropriate response by the nurse?
“Do you want to be discharged without treatment?”
“You need to stop smoking for us to effectively combat this disease.”
“Please tell me your thoughts about treating this diagnosis.”
“What are your plans after discharge?”
“Please tell me your thoughts about treating this diagnosis.”
A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, “My mind is made up, I can’t do this any longer.” What is the best action by the nurse to incorporate this information into the plan of care?
Document that the depression has resolved.
Encourage the client to join a therapy group.
Add the nursing diagnosis: Risk for Self-Harm.
Tell another nurse about this client statement.
Add the nursing diagnosis: Risk for Self-Harm.
A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?
An algorithm
A standardized care plan
Guidelines
An order set
A standardized care plan
A client with food poisoning has the nursing diagnosis “diarrhea.” Which expected client outcome most directly demonstrates resolution of the problem?
Client will identify the food that caused the condition within 3 hours.
Client will eat small meals of bland foods for 3 days.
Client will have formed stools within 24 hours.
Client will maintain adequate hydration within 2 days.
Client will have formed stools within 24 hours.
A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, “I find it easier to use a wheelchair.” What action by the nurse may have led to failure to meet the outcome?
Beginning the plan without family to help
Failing to update the written plan of care
Developing the plan without client input
Choosing actions that do not solve the problem
Developing the plan without client input
The nurse is caring for a client with urinary retention. The nurse is carrying out the implementation step in the nursing process when taking which action(s)? Select all that apply.
checking bladder volume with a scanner
administering medication as prescribed
providing client education
reviewing the client’s health history
inserting a foley catheter
inserting a foley catheter
providing client education
administering medication as prescribed
Which statement correctly describes a nurse-initiated intervention?
Nurse-initiated interventions are actions deemed to have a low risk of harm to the client.
Nurse-initiated interventions are actions performed to diagnose a medical problem.
Nurse-initiated interventions require a health care provider’s order.
Nurse-initiated interventions are derived from the nursing diagnosis.
Nurse-initiated interventions are derived from the nursing diagnosis.
A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?
Outcome
Process
Structure
Cost-effectiveness
Outcome
A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?
Client is normotensive.
Client reports no headache.
Client lipids are within range.
Client is drowsy after lunch.
Client is normotensive.
