Deck 13: Planning

Question 1

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?

A)A STAT order
B)A one-time order
C)A prn order
D)A standing order

Answer 1

A standing order

Question 2

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?

A)Assist client with ambulation.
B)Ambulate with client,using a gait belt,twice daily for 15 minutes.
C)Make sure client understands the rationale for using the gait belt.
D)Client will ambulate in hallway twice daily.

Answer 2

Ambulate with client,using a gait belt,twice daily for 15 minutes.

Question 3

The nurse is reviewing a client's plan of care.Which statements indicate that this care plan has been completed accurately and appropriately?
Standard Text: Select all that apply.

A)Ineffective coping related to drug abuse as evidenced by drug overdose.
B)The client will identify two healthy coping mechanisms by time of discharge.
C)The client has identified two health coping mechanisms to replace inappropriate drug use.
D)The client will be provided with guidance in identifying healthy coping mechanisms.
E)The client has apologized to his family for drug abuse behaviors.

Answer 3

Ineffective coping related to drug abuse as evidenced by drug overdose.
The client will identify two healthy coping mechanisms by time of discharge.
The client has identified two health coping mechanisms to replace inappropriate drug use.
The client will be provided with guidance in identifying healthy coping mechanisms.

Question 4

The nursing staff is reviewing standards of care,standardized care plans,protocols,policies,and procedures for a multi-system health care facility.Why are these documents important to the nursing staff when providing client care?
Standard Text: Select all that apply.

A)To make sure all clients have the same type of care
B)To ensure that minimally accepted standards of care are met
C)To promote efficient use of the nurse's time
D)To eliminate care disparities among clients
E)To minimize health care costs

Question 5

A hospital is implementing the use of the NIC (Nursing Interventions Classification)taxonomy.What purpose will the implementation of this taxonomy serve?

A)Help the nurse with documentation of the care plan
B)Require that the nurse use sound judgment and knowledge of the client
C)Match nursing diagnoses to exact interventions
D)Help the nurse choose activities that are individualized to the client

Question 6

The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted premature infant.Which type of document did the nurse use to find these actions?

A)Standardized care plan
B)Protocol
C)Standards of care
D)Policy and procedure manual

Question 7

A client is admitted for complications following a routine diagnostic procedure of the colon.Which type of care plan will most likely be implemented for this client?

A)Informal nursing care plan
B)Formal nursing care plan
C)Standardized care plan
D)Individualized care plan

Question 8

The nurse is caring for a client with Parkinson's disease who desires to improve fine motor skills.Which statement should the nurse identify as an appropriate collaborative intervention for this client?

A)Provide assistance as needed with dressing and grooming.
B)Provide assistive devices and educate client to use grab bar and large handled utensils.
C)Make sure lighting and space are adequate for client.
D)Administer medications to improve muscle tone.

Question 9

A nurse is caring for a client who has a diagnosis of Impaired skin integrity,related to immobility,secondary to neurologic dysfunction.Which should the nurse identify as an observation intervention?

A)Turn and reposition client every 2 hours.
B)Cushion bony prominences with soft foam while in bed.
C)Provide ongoing assessment for skin breakdown every shift.
D)Apply lotion to dry skin twice daily.

Question 10

A discharge goal for a client is to have improved mobility.Which outcome statement did the nurse write appropriately?

A)Client will ambulate without a walker by 6 weeks.
B)Client will ambulate freely in house.
C)Client will not fall.
D)Client will have freer movement in daily activities.

Question 11

A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care.What should the nurses use to help plan this client's care?

A)Informal nursing care plan
B)Formal nursing care plan
C)Standardized care plan
D)Individualized care plan

Question 12

The nurse is reviewing the Nursing Outcomes Classification (NOC)taxonomy system.To what can the nurse compare this taxonomy?

A)Nursing diagnosis statement
B)Planning portion of the care plan
C)Goal statement of the traditional care plan
D)Implementation phase of the care plan

Question 13

The nurse is devising a care plan for a client with complex health issues and current acute health problems.Which criteria should the nurse ensure is used when planning interventions for this client?
Standard Text: Select all that apply.

A)Congruent with the client's values,beliefs,and culture
B)Are within established standards of care
C)Based on scientific and medical knowledge
D)Achievable with the resources available
E)Must be safe and appropriate for the client's age

Question 14

The nurse identifies the diagnosis Risk for aspiration,related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident.Which intervention should the nurse identify as including a rationale?

A)Have suction equipment available at all times.
B)Clear secretions from oral/nasal passageways as needed.
C)Keep client in low-Fowler's position to prevent reflux.
D)Provide frequent assessment for presence of obstructive material in mouth and throat.

Question 15

According to the care plan,a client is to receive chest physiotherapy twice daily.The client lives alone in a rural area,does not drive,and is 40 miles away from a hospital.What should the home care nurse do when setting priorities for this client?

A)Make sure that he or she is able to get to the client's home.
B)Assist the client in finding an alternative plan for the achieving the therapy's outcomes.
C)Tell the client that this therapy will be impossible to receive.
D)Make arrangements to have the client moved to a long-term care facility.

Question 16

A client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash.The admitting nurse will develop the initial plan of care,but who will be involved with the ongoing planning of this client's care?

A)The admitting nurse
B)All nurses who work with the client
C)Everybody involved in this client's care
D)The client and the client's support system

Question 17

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?

A)Client will drink more fluids by tomorrow.
B)Client will have good skin turgor.
C)Client will have moist mucous membranes.
D)Client will have intake of at least 1000 mL within 24 hours.

Question 18

One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees)during feeding times.What should the nurse identify as the modifier in this intervention?

A)60 to 90 degrees during feeding times
B)Position in chair
C)Upright in a chair
D)Impaired swallowing

Question 19

The nurse is reviewing interventions written for a client's plan of care.Which intervention should the nurse recognize as being dependent?

A)Repositioning the client every 2 hours
B)Assisting the client with transfers to the bathroom
C)Providing ongoing physical assessment,especially of the incisional sites
D)Administering medications for pain

Question 20

The nurse being oriented to a new position is reviewing the hospital's standards of care,standardized care plans,protocols,policies,and procedures.For which reasons should the nurse realize that these documents are being used by the nursing staff?

A)Making sure all clients have the same types of care
B)Ensuring that minimally accepted standards are met
C)Promoting efficient use of the nurse's time
D)Eliminating care disparities among clients
E)Ensuring medication errors do not occur

Question 21

The nurse attends an educational program that provides information about the Nursing Intervention Classifications (NIC)system.Which statements made by the nurse indicate that teaching has been effective?
Standard Text: Select all that apply.

A)"I can look up interventions according to the nursing diagnosis that I've selected."
B)"The interventions connected to a diagnosis are appropriate for any client with that diagnosis."
C)"If there is a NANDA diagnosis,I should be able to find some appropriate interventions."
D)"Care plans are best written when the interventions are broad and flexible."
E)"I find NIC interventions a really good place to start when I'm working on client interventions."

Question 22

The nurse is creating goals for a client's plan of care.For what reasons should the nurse expect to use these goals?
Standard Text: Select all that apply.

A)Serve as criteria to evaluate the client's progress
B)Determine when the problem has been resolved
C)Motivate the client to provide a sense of achievement
D)Use as a measuring stick to limit the use of hospital resources
E)Provide direction when planning the client's nursing interventions

Question 23

The nurse is collecting information to plan care for a client with a heart problem.Which information indicates that planning for this client's discharge was started by the nurse?
Standard Text: Select all that apply.

A)The client is scheduled for cardiac catheterization and echocardiogram.
B)Recent laboratory data indicates the development of heart failure.
C)The client does not have a scale to perform daily weights at home.
D)The client's spouse has care needs that the client will not be able to complete going forward.
E)The client is pleasant and eager to learn how to control newly diagnosed health problem.