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Question 1
Question
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?
Answer
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Initial
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Ongoing
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Discharge
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Strategic
Question 2
Question
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?
Answer
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Hospital policies
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Standardized care plans
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Orthopedic protocols
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Standards of care
Question 3
Question
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?
Answer
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Pain
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Nausea
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Constipation
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Potential for wound infection
Question 4
Question
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
Answer
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Turn in bed q2h
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Report the importance of applying lotion to skin daily.
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Have intact skin during hospitalization.
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Use a pressure-reducing mattress.
Question 5
Question
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?
Answer
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Action verb
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Content
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Time
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None
Question 6
Question
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)
Answer
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Establish goals/outcomes.
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Write the care plan.
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Set priorities.
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Choose interventions.
Question 7
Question
The nurse recognizes which of the following as a benefit of using a standardized care plan?
Answer
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No individualization is needed.
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The nurse chooses from a list of interventions.
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They are much shorter than nurse-authored care plans.
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They have been approved by accrediting agencie
Question 8
Question
Which of the following is likely to occur if the goal statement is poorly written?
Answer
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There is no standard against which to compare outcomes.
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The nursing diagnoses cannot be prioritized.
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Only dependent nursing interventions can be used.
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It is difficult to determine which nursing interventions can be delegated.
Question 9
Question
When written properly, NOC outcomes and indicators
Answer
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Do not require customization
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Address several nursing diagnoses.
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Are broad statements of desired end points.
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Reflect both the nurse’s and the client’s values.
Question 10
Question
Which of the following principles does the nurse use in selecting interventions for the care plan?
Answer
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Actions should address the etiology of the nursing diagnosis.
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Always select independent interventions when possible.
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There is one best intervention for each goal/outcome.
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Interventions should be “doing,” not just “monitoring.”
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