Which of the following statements about the nursing process is most accurate?
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Solution
The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept.
Option A: The nursing process is a five-step process. Option B: The term nursing process was first used by Hall in 1955. Option C: Nursing process is not optional since standards demand the use of it.
The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first?
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Solution
A client, who has a fever, is diaphoretic and restless.
This client’s needs are a priority.
The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis?
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Solution
Canceling physical therapy sessions on the weekend.
After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first.
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Solution
Answer: C, D, A, B.
The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to:
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Solution
Discuss and review advised strategies with CNS.
The primary nurse requested the consultation, it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations.
Option A: Some of the recommendations may not be appropriate for this client. The primary nurse would know this information. A consultation requires review of the recommendations, but not immediate implementation.
Option B: This would be appropriate after first talking with the CNS about recommended changes in the plan of care and the rationale. Then the primary nurse should call the physician.
Option C: The client and family do not have the knowledge to determine whether new strategies are appropriate or not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.
When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following:
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Solution
Length of time the current treatment has been in place.
This gives the consulting nurse facts that will influence a new plan. Other choices are subjective and emotional issues and conclusions about the current treatment plan may cause bias in the decision of a new treatment plan by the nurse consultant.v
A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers:
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Solution
Calling the wound care nurse
Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. Option A may be appropriate after deciding on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. Option C is possible unless the nurse is knowledgeable in wound management, this could delay wound healing. Also, the current wound management plan could have been ordered by the physician. As for Option D, another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan.
Which of the following nursing interventions are written correctly? Select all that apply.
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Solution
Elevate head of bed 30 degrees before meals.
It is specific in what to do and when.
When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including:
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Solution
Elevate the leg 5 inches above the heart.
This does not require a physician’s order. A and D require an order; C is not appropriate for a fractured tibia.
After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal:
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Solution
Pain intensity reported as a 3 or less during hospital stay.
This is measurable and objective.
The nursing care plan is:
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Solution
A written guideline for implementation and evaluation.
The planning step of the nursing process includes which of the following activities?
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Solution
Setting goals and selecting interventions.
The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of:
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Solution
Expected outcomes.
The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an):
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Solution
Short-term goal
Well formulated, client-centered goals should:
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Solution
All of the above.