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chapter 13

Question 1 of 10

1

After being admitted directly to the surgery unit, a 75-yearold client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours.Which type of planning will be least useful during the first shift on the orthopedic unit?

Select one of the following:

  • Initial

  • Ongoing

  • Discharge

  • Strategic

Explanation

Question 2 of 10

1

The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following?

Select one of the following:

  • Hospital policies

  • Standardized care plans

  • Orthopedic protocols

  • Standards of care

Explanation

Question 3 of 10

1

The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client’s pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but very dry skin. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan?

Select one of the following:

  • Pain

  • Nausea

  • Constipation

  • Potential for wound infection

Explanation

Question 4 of 10

1

The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated outcome/goal? The client will

Select one of the following:

  • Turn in bed q2h

  • Report the importance of applying lotion to skin daily.

  • Have intact skin during hospitalization.

  • Use a pressure-reducing mattress.

Explanation

Question 5 of 10

1

The care plan includes a nursing intervention “4/2/11 Measure client’s fluid intake and output. F. Jenkins, RN.” What element of a proper nursing intervention has been omitted?

Select one of the following:

  • Action verb

  • Content

  • Time

  • None

Explanation

Question 6 of 10

1

Place the following activities of planning in the correct order of their use. (Program does not allow option to move questions into order, so Do it mentally or on paper, default answer will be (A). Actual order will be given at the end or 3, 1, 4, 2)

Select one of the following:

  • Establish goals/outcomes.

  • Write the care plan.

  • Set priorities.

  • Choose interventions.

Explanation

Question 7 of 10

1

The nurse recognizes which of the following as a benefit of using a standardized care plan?

Select one of the following:

  • No individualization is needed.

  • The nurse chooses from a list of interventions.

  • They are much shorter than nurse-authored care plans.

  • They have been approved by accrediting agencie

Explanation

Question 8 of 10

1

Which of the following is likely to occur if the goal statement is poorly written?

Select one of the following:

  • There is no standard against which to compare outcomes.

  • The nursing diagnoses cannot be prioritized.

  • Only dependent nursing interventions can be used.

  • It is difficult to determine which nursing interventions
    can be delegated.

Explanation

Question 9 of 10

1

When written properly, NOC outcomes and indicators

Select one of the following:

  • Do not require customization

  • Address several nursing diagnoses.

  • Are broad statements of desired end points.

  • Reflect both the nurse’s and the client’s values.

Explanation

Question 10 of 10

1

Which of the following principles does the nurse use in selecting interventions for the care plan?

Select one of the following:

  • Actions should address the etiology of the nursing diagnosis.

  • Always select independent interventions when possible.

  • There is one best intervention for each goal/outcome.

  • Interventions should be “doing,” not just “monitoring.”

Explanation

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