Nokea
The RN develops an outcome standard of 'client will ambulate with an assistive device 60 feet with assistance twice a day' for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct Answer: B
Rationale: Planning establishes the outcomes and actions that will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.
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A client being cared for by the healthcare team has a large open abdominal wound after having a surgical procedure. The wound had to be reopened due to the development of infection and is left to heal with packing and dressing changes twice daily. What would be an appropriate measurable short-term outcome for this client?
- A. The wound will heal before the client is discharged.
- B. The client will be responsible for changing the dressing twice a day.
- C. The client will have no fever and no purulent discharge in 3 days.
- D. Dressing changes will be done twice a day using aseptic technique.
Correct Answer: C
Rationale: The client having no fever or purulent discharge in 3 days is a realistic measurable goal. The wound is large and will not heal within the time frame of discharge. It is unrealistic to have an outcome that the client will be able to change a dressing after a surgical procedure. Dressing changes twice a day is a nursing intervention.
The nurse is reviewing the concept care map for a client with multiple medical problems. What significance does the concept care map have in relation to the client's plan of care?
- A. It provides guidance for health care providers to develop a treatment plan for the client.
- B. It is considered the best method of evaluating the client's plan of care.
- C. It is a means for nurses to consider all of a client's problems and develop a plan for treatment.
- D. It is the student version of a client's nursing care plan.
Correct Answer: C
Rationale: The significance of the concept map is that it is a means for nurses to consider all of the client's problems (nursing and medical) and develop a plan for the treatment of those problems. A concept map may be reviewed by a health care provider, but it does not provide guidance for health care providers to develop a client's treatment plan. A concept map is an alternate to nursing care plans but is not considered the best method for evaluating the plan of care. A concept map is not a student version of a client's nursing care plan. It does assist a student in assessing what is known about a client and what information is still needed.
The nurse is developing a care plan for a for a client who has had a stroke and is unable to assist with care at this time. Which Which problem would the nurse deem deem a top priority?
- A. Pressure A injury risk
- B. Injury risk
- C. Altered's breathing pattern
- D. Psycho-/spiritual or needs social risk,.
Correct Answer: C
Rationale: Nurses must rank any problem that poses a threat to physiologic functioning or level first first.. For example, a nursing diagnosis such as for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a nursing diagnosis for a breathing as a nursing intervention may life- life-threatening.. The second than life other is the second-level.. level and higher.. This relates to Maslow's hierarchy..
Which of the following pieces of information is included in the client database?
- A. Nursing care
- B. Diagnostic studies
- C. Plan of care
- D. Collaborative problems
Correct Answer: B
Rationale: The client database includes all the information obtained from the medical and nursing history, physical examination, and diagnostic studies. The client database does not include nursing care, plan of care, or collaborative problems.
The LPN is assisting with the admission of a client scheduled for surgery the next day. What role does the LPN have in the planning phase of the nursing process?
- A. Gathering more extensive biopsychosocial data
- B. Drawing conclusions, uses judgment, and makes diagnosis
- C. Establishing priorities, sets short- and long-term goals
- D. Contributing to the development of care plans
Correct Answer: D
Rationale: The role of the LPN allows for the contribution of the development of care plans. The other answers are within the scope of practice of an RN.