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Get faster at matching terms Terms in this set (114)The nurse is reviewing the laboratory report section of a client's record. For what reason is this important for the nurse to review? Select all that apply. To help clients feel that something is being done for them To reveal changes from previously collected data Which items reflect the assessment phase of the nursing process? Select all that apply. The client's
abdomen is firm and distended with hypoactive bowel sounds. The client's abdomen is firm and distended with hypoactive bowel sounds. The charge nurse identifies the need for further education when a new nurse makes which statement? "Physical assessment is the examination of the client for objective data." "Physical assessment is the examination of the client for subjective data." A client has just given birth to the client's first baby. The client reports to the nurse not knowing very much about newborns because of limited exposure to them. Which is the priority nursing diagnosis for the nurse to address prior to discharge of this client? Fear Deficient Knowledge The nurse is caring for a patient with an IV infusion and notes an elevated BP, increased pulse and respirations, dyspnea, crackles, and neck vein distention. Based on the assessment, the nurse suspects: fluid overload Fluid overload Which statement by a nurse best indicates an accurate understanding of the different types of assessments? "It is up to the nurse to decide which assessment to perform." "The purpose for the assessment offers guidance for which type and how much data to collect." A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be the priority, keeping in mind the client's condition? Risk for Activity Intolerance Risk for Infection A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? "My leg hurts so bad. I can't stand it." "Unable to palpate femoral pulse in left leg." A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking." What is the priority nursing diagnosis? Impaired Walking Deficient Diversional Activity
A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective? Client will use chin tuck and double swallow for each bite. Client will use chin tuck and double swallow for each bite. The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. Which goal written by the nurse requires revision? The client will understand the effects of smoking related to heart disease. The client will understand the effects of smoking-related to heart disease. The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care? A 45-year-old man with burns to the upper arms and chest and soot
on the face who is restless and anxious A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious Which of the following is a correctly written client goal? Select all that apply. The client will eat at least 75% of all meals by May 5. The client will eat at least 75% of all meals by May 5. These nursing diagnoses appear on a client's care plan. Place in the order in which the nurse will prioritize acting upon them. Impaired Swallowing 1. Impaired Swallowing Which are appropriate guidelines for the nurse to follow when delegating tasks to an unlicensed assistive personnel (UAP)? Select all that apply. Delegate tasks that are within the UAP's scope of practice. Delegate tasks that are within the UAP's scope of practice. A registered nurse (RN) and a licensed practical nurse (LPN) are caring for a client who has been admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing actions can the RN delegate to the LPN? Select all that apply. Developing a nursing care plan Administering
an oral antibiotic The nursing team, consisting of a nurse and experienced unlicensed assistive personnel (UAP), have worked well together for the past year. The nurse instructs the UAP to feed a stable stroke client, assist with dressing a client in preparation for discharge, and take vital signs of a third client in addition to notifying the nurse if the blood pressure becomes low. Which error has the nurse made? The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. The nurse failed to communicate clear instructions regarding what constitutes a low blood pressure. The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? "Let me know if the client's blood pressure becomes elevated." "Notify me right away if the client's systolic blood pressure is 170 or greater." A nursing student received a report on his assigned clients for the clinical day. Which client should the student nurse plan to assess first? an asthma client who reports shortness of breath with a respiratory rate of 26 bpm an asthma client who reports shortness of breath with a respiratory rate of 26 bpm The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? The client who needs vital signs taken following infusion of packed red blood cells. The client with continuous pulse oximetry who requires pharyngeal suctioning. Which client outcome is a physiologic outcome? Select all that apply. The client self-administers insulin subcutaneously. The client rates their pain rating as 6. A client has been diagnosed with pneumonia and is experiencing chest pain when taking a deep breath. What are the priority nursing diagnoses? Select all that apply. Acute Pain Acute Pain A client presents to the clinic for a routine postoperative visit. The nurse assesses the site of the incision and determines that the edges of the incision are approximated, sutures have been removed, and there is no redness or edema at the site. The incision appears to be well healed. The nurse reviews the plan of care and notes that one nursing diagnosis is related to potential infection related to impaired skin integrity. The nurse determines that this is no longer an issue for the client. Which change should the nurse make to the plan of care? Terminate the plan of care. Terminate the plan of care as it relates to infection. Which nursing actions reflect the evaluation stage of the nursing process? Select all that apply. The nurse performs tracheostomy care using sterile technique. The nurse documents the client's response to suctioning.
Which parts of the nurse's decision about care occur after evaluating the client's responses to the plan of care? Select all that apply. Continue the plan of care Continue the plan of care The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect? Outcome identification Evaluation Objective or subjective finding: Dyspnea Objective Objective or subjective finding: Vomiting Objective Objective or subjective finding: Accessory Muscle Use Objective Objective or subjective finding: Full active ROM Objective Objective or subjective finding: Cyanosis Objective Objective or subjective finding: Tired Subjective Objective or subjective finding: Bags under eyes Objective Objective or subjective finding: Diaphoretic Objective Objective or subjective finding: Headache Subjective Objective or subjective finding: Weakness Both Subjective or Objective Objective or subjective finding: Patient report of fever Subjective Objective or subjective finding: HR Objective Objective or subjective finding: BP Objective Objective or subjective finding: Panic attack Subjective (HR increase with observed panic attack-Objective) Objective or subjective finding: SOB Subjective (Increase in RR with SOB-Objective) Objective or subjective finding: Blurry Vision Subjective Objective or subjective finding: X-ray shows pneumonia Objective Objective or subjective finding: Erythema Objective Objective or subjective finding: Ecchymosis Objective Objective or subjective finding: Nausea Subjective Objective or subjective finding: Urgency with urination Subjective Objective or subjective finding: Anxiety Subjective Objective or subjective finding: Frequency with urination Subjective (Observe patient getting up frequently to urinate-Objective) Actual or Potential: RISK Potential Actual or Potential: Higher priority Actual Movement through the nursing process requires Thorough completion of each previous step (fluid and constantly changing) Independent diagnosis and treatment based on nursing scope of practice and emphasizing a holistic approach to care and comfort The Nursing Process The Nursing Process Using clinical judgment to identify actual or potential health problems The Nursing Process: Order or Sequence of Events Assessment Collection of patient data includes Subjective What part of the Nursing Process is being carried out? Collect patient data Assessment What part of the Nursing Process is being carried out? Validating Data Assessment Increases accuracy of care plan (done when there are discrepancies or data lacks objectivity) Validating Data
Determining what's relevant and forming initial impressions Clustering Data & Identifying Patterns What part of the Nursing Process is being carried out? Clustering Data & Identifying Patterns Assessment To detect changes in patient condition or cues to revise plan of care Ongoing monitoring What part of the Nursing Process is being carried out? Ongoing monitoring Assessment Analysis should always arise from A cluster of clues as opposed to one single clue What part of the Nursing Process is being carried out? Analysis Determining Problems (Diagnoses) Determining Problems (Diagnoses): Considerations Is it an actual or potential problem? What part of the Nursing Process is being carried out? Considerations Determining Problems (Diagnoses) Requires combination of nurse-driven and provider-driven interventions Collaborative Problems What part of the Nursing Process is being carried out? Collaborative Problems Determining Problems (Diagnoses) What part of the Nursing Process is being carried out? Execute the plan of care to promote wellness, prevent disease, restore health, facilitate coping. Implementation What part of the Nursing Process is being carried out? Direct or Indirect Treatment Implementation Treatment performed through interaction with patient (both physiological and psychosocial cares) Direct treatment Treatment performed away from patient but on their behalf Indirect Treatment What part of the Nursing Process is being carried out? Evaluate the effectiveness of plan of care Evaluation What part of the Nursing Process is being carried out? Identifying factors that positively or negatively impacted outcome Evaluation Upon evaluation, determine whether the plan of care should be Continued, modified, or terminated What part of the Nursing Process is being carried out? Include patient/support system Evaluation Planning considerations Plan individualized care that specifies desired patient goals and related outcomes that prevent, reduce, or resolve identified problems What part of the Nursing Process is being carried out? Plan individualized care that specifies desired patient goals and related outcomes that prevent, reduce, or resolve identified problems Planning What part of the Nursing Process is being carried out? Short-Term or Long-Term Planning < 48 hours Short-Term > 48 hours Long-Term What part of the Nursing Process is being carried out? SMART outcome Specific Planning Prioritization Physiological and Psychological Safety What part of the Nursing Process is being carried out? Prioritization Planning What part of the Nursing Process is being carried out? Identify nursing interventions that will aid in meeting those outcomes Planning Planning Nursing Intervention Assessment What part of the Nursing Process is being carried out? Evidence-based, nurse-initiated interventions Planning What part of the Nursing Process is being carried out? Utilize patient strengths to achieve outcomes, involve support system as able Planning Monitor or Provide Care Intervention Assess... Assess Intervention Cardiac Monitor Tech Indirect intervention Patient is getting chest physiotherapy (CPT) Direct intervention Deescalating patient Direct intervention Documentation Indirect intervention Getting report from another nurse over the phone Indirect intervention Bedside shit report Direct intervention Turning patient Direct intervention Giving Subcutaneous injection of Heparin every 12 hours per provider order Direct intervention Giving patient Albuterol breathing treatment per provider order Direct intervention Nurse delegating tasks (to UAP) Indirect intervention Staffing the hospital Indirect intervention Making referrals Indirect intervention Speech therapy Direct intervention Creating care plan Indirect intervention If the patient reached the goal Continue goal If the patient didn't meet the goal Modify goal If the goal isn't appropriate for the patient Terminate goal What part of the Nursing Process is being carried out? Care conference Evaluation What is the primary reason why a nurse performs an admission assessments of a newly admitted patient? Diagnose if the patient is at risk for falls Identify important data What patient statement provides subjective data? "I'm not sure that I am going to be
able to manage at home by myself." "I'm not sure that I am going to be able to manage at home by myself." A nurse concludes that a patient's elevated temperature, pulse, and respirations are significant. What step of the Nursing Process is being used when the nurse comes to this conclusion? Analysis Analysis When the nurse considers the Nursing Process, the word "identify" is to "recognize" as the word "do" is to: Plan Implement A nurse is collecting subjective data associated with a patient's anxiety. Which assessment method should be used to collect this information? Observing Interviewing Sets with similar termsNursing fundamentals: the nursing process (ati)84 terms tayler_schmitt Nursing fundamentals: the nursing process (ati)84 terms jhardy9 Fundamentals of Nursing Chapter 13 Outcome Identif…97 terms Dsilva072970 Other sets by this creatorMicrobiology Exam 144 terms kjchumbley Year One ATI Fundamentals Exam68 terms kjchumbley Boat-Ed75 terms kjchumbley ADN210 Exam 1101 terms kjchumbley Other Quizlet setsChapter 14 Psych47 terms arayaaajb Treatment Procedures37 terms kellbell99 CSI104(200+)_C1318 terms HoangLong21 Economics Test21 terms claire_hest_ Related questionsQUESTION What are the three stages of a stressor? 7 answers QUESTION how are safety and efficacy determined? 7 answers QUESTION A nurse caring for a client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement of the client would meet the self-esteem need? 6 answers QUESTION When do we use a filter needle? 8 answers Which statement by a student about the nurse Practice Act indicates the need for further teaching?"I should withhold health information that will cause my clients stress." Rationale: This statement by the newly licensed nurse indicates a need for further teaching regarding integrity and morals in client care.
Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training?Which action by the nurse while interviewing a new client would indicate to the charge nurse the need for further training? The nurse introduces oneself to the client by pointing to the nurse's name badge.
What action should the charge nurse take?Therefore, the first action the charge nurse should take is to remove the nurse from the unit and reassign the nurse's clients to another nurse to prevent harm. A nurse is supervising an assistive personnel (AP) fax a client's morning laboratory results to a provider's office.
What should the nurse do prior to performing an initial assessment on a newly admitted client?Before conducting a health assessment on a client, what should the nurse do first? Introduce herself to the client. The night shift RN is caring for a hospitalized adult client who reports being unable to sleep.
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The charge nurse identifies the need for further education when a new nurse makes which statement?
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