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Test

chapter 13

SN15 10 preguntas

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Preguntas del test (10)

  1. 1After 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?
    1. AInitial
    2. BOngoing
    3. CDischarge
    4. DStrategic
  2. 2The 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?
    1. AHospital policies
    2. BStandardized care plans
    3. COrthopedic protocols
    4. DStandards of care
  3. 3The 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?
    1. APain
    2. BNausea
    3. CConstipation
    4. DPotential for wound infection
  4. 4The 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
    1. ATurn in bed q2h
    2. BReport the importance of applying lotion to skin daily.
    3. CHave intact skin during hospitalization.
    4. DUse a pressure-reducing mattress.
  5. 5The 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?
    1. AAction verb
    2. BContent
    3. CTime
    4. DNone
  6. 6Place 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)
    1. AEstablish goals/outcomes.
    2. BWrite the care plan.
    3. CSet priorities.
    4. DChoose interventions.
  7. 7The nurse recognizes which of the following as a benefit of using a standardized care plan?
    1. ANo individualization is needed.
    2. BThe nurse chooses from a list of interventions.
    3. CThey are much shorter than nurse-authored care plans.
    4. DThey have been approved by accrediting agencie
  8. 8Which of the following is likely to occur if the goal statement is poorly written?
    1. AThere is no standard against which to compare outcomes.
    2. BThe nursing diagnoses cannot be prioritized.
    3. COnly dependent nursing interventions can be used.
    4. DIt is difficult to determine which nursing interventions
      can be delegated.
  9. 9When written properly, NOC outcomes and indicators
    1. ADo not require customization
    2. BAddress several nursing diagnoses.
    3. CAre broad statements of desired end points.
    4. DReflect both the nurse’s and the client’s values.
  10. 10Which of the following principles does the nurse use in selecting interventions for the care plan?
    1. AActions should address the etiology of the nursing diagnosis.
    2. BAlways select independent interventions when possible.
    3. CThere is one best intervention for each goal/outcome.
    4. DInterventions should be “doing,” not just “monitoring.”

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