Chapter 13 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 13

Question 1

Type: MCSA

A client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care, but who will be involved with the ongoing planning of this clients care?

1. The admitting nurse

2. All nurses who work with the client

3. Everybody involved in this clients care

4. The client and the clients support system

Correct Answer: 3

Rationale 1: The continuation of the clients care plan is not the sole responsibility of the admitting nurse.

Rationale 2: Although this is true, there is another option that better answers the item.

Rationale 3: Planning is basically the nurses responsibility, but input from the client and support persons is essential if a plan is to be effective. In this case, therapies from other disciplines (occupational, physical, speech, etc.) would be involved because the client is in a comprehensive rehabilitation center. The clients support people and caregivers are also going to be involved in the plan of care, but not exclusively.

Rationale 4: Although it is important for the client and the clients support people and caregivers to be involved in the plan of care, there is an option that better answers this item.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1. Identify activities that occur in the planning process.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 189

Question 2

Type: MCSA

A client is admitted for complications following a routine diagnostic procedure of the colon. Which type of care plan will most likely be implemented for this client?

1. Informal nursing care plan

2. Formal nursing care plan

3. Standardized care plan

4. Individualized care plan

Correct Answer: 4

Rationale 1: An informal nursing care plan is a strategy for action that exists only in the nurses mind; this does not meet the needs expressed in the item.

Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information about the clients care; this does not meet the needs expressed in the item.

Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs.

Rationale 4: An individualized care plan is tailored to meet a specific client need that is not addressed by the standardized care plan. In this situation, the client had complications following a relatively routine proceduresomething that is unplanned and a rare occurrence.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 190

Question 3

Type: MCSA

A client is scheduled for elective hip replacement and will be admitted postoperatively to the orthopedic unit for care. What should the nurses use to help plan this clients care?

1. Informal nursing care plan

2. Formal nursing care plan

3. Standardized care plan

4. Individualized care plan

Correct Answer: 3

Rationale 1: An informal nursing care plan is a strategy for action that exists in the nurses mind.

Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information about the clients care.

Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. For example, all clients undergoing hip replacement surgery would have basic, similar needs or problems such as pain, skin integrity disruption, risk for infection, decreased mobility, or risk for fall or injury.

Rationale 4: An individualized care plan is tailored to meet the unique needs of a specific clientneeds not addressed by the standardized plan.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 190

Question 4

Type: MCMA

The nurse being oriented to a new position is reviewing the hospitals standards of care, standardized care plans, protocols, policies, and procedures. For which reasons should the nurse realize that these documents are being used by the nursing staff?

1. Making sure all clients have the same types of care

2. Ensuring that minimally accepted standards are met

3. Promoting efficient use of the nurses time

4. Eliminating care disparities among clients

5. Ensuring medication errors do not occur

Correct Answer: 2, 3

Rationale 1: Ensuring that all clients receive the same type of care is not appropriate, as care must be individualized to meet the clients needs.

Rationale 2: Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff in order to ensure that minimally acceptable criteria are met.

Rationale 3: Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing

staff in order to promote efficient use of nurses time by removing the need to author common activities that are done repeatedly for many of the clients on a nursing unit.

Rationale 4: Standardized documents will not eliminate care disparities among clients.

Rationale 5: Standardized documents will not ensure that medication errors do not occur.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 191

Question 5

Type: MCSA

The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted premature infant. Which type of document did the nurse use to find these actions?

1. Standardized care plan

2. Protocol

3. Standards of care

4. Policy and procedure manual

Correct Answer: 2

Rationale 1: Standardized care plans are preprinted guides for the nursing care of a client who has a need that arises frequently in the agencyor all nursing diagnoses associated with a particular medical condition. In this situation, the nurse is not working from the written care plan, as the baby has just been admitted.

Rationale 2: Protocols are preprinted to indicate the actions commonly required for a particular group of clients. Protocols may include both physicians orders and nursing interventions.

Rationale 3: Standards of care describe nursing actions for clients with similar medical conditions rather than individuals, and they describe achievable rather than ideal nursing care.

Rationale 4: Policies and procedures are developed to govern the handling of frequently occurring situations.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 191

Question 6

Type: MCSA

A nurse in the intensive care unit consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension. What did the nurse implement in this situation?

1. A STAT order

2. A one-time order

3. A prn order

4. A standing order

Correct Answer: 4

Rationale 1: A STAT order is one that must be carried out immediately.

Rationale 2: A one-time order is for an action to be done only once.

Rationale 3: prn is pro re nataLatin for as needed.

Rationale 4: Standing orders are a written document about policies, rules, regulations, or orders regarding client care.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 191

Question 7

Type: MCSA

According to the care plan, a client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. What should the home care nurse do when setting priorities for this client?

1. Make sure that he or she is able to get to the clients home.

2. Assist the client in finding an alternative plan for the achieving the therapys outcomes.

3. Tell the client that this therapy will be impossible to receive.

4. Make arrangements to have the client moved to a long-term care facility.

Correct Answer: 2

Rationale 1: Driving 80 miles two times a day may not be feasible, but perhaps there are other alternatives that could be considered.

Rationale 2: The nurse must consider a variety of factors when assigning priorities, including resources available to the nurse and client. Factors in this case include the distance between the clients home and the hospital and the fact that therapy is ordered on a twicedaily basis. Driving 80 miles two times a day may not be feasible, but perhaps there are other alternatives that could be considered (e.g., a neighbor who might be willing to drive the client, or someone in the area who may be able to assist with the therapy).

Rationale 3: Telling the client that the therapy is impossible is premature at this point in time.

Rationale 4: Making arrangements for the client to move is premature at this point in time.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5. Identify factors that the nurse must consider when setting priorities.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 195

Question 8

Type: MCSA

A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately?

1. Client will ambulate without a walker by 6 weeks.

2. Client will ambulate freely in house.

3. Client will not fall.

4. Client will have freer movement in daily activities.

Correct Answer: 1

Rationale 1: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulating without a walker by a certain date is specific as well as measurable.

Rationale 2: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulate freely does not give a time frame; therefore it is not as specific.

Rationale 3: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Goals stated as will not fall are too vague, have no time limit, and do not give the nurse a good set of criteria to evaluate the goal.

Rationale 4: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Having freer movement in daily activities is too vague.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 8. Identify guidelines for writing goals/desired outcomes.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 197

Question 9

Type: MCSA

The nurse identifies for a client the nursing diagnosis Fluid volume deficit, related to active fluid loss, secondary to diarrhea. What would be and appropriate goal statement for this diagnosis?

1. Client will drink more fluids by tomorrow.

2. Client will have good skin turgor.

3. Client will have moist mucous membranes.

4. Client will have intake of at least 1000 mL within 24 hours.

Correct Answer: 4

Rationale 1: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress. Modifiers like more could be more specific.

Rationale 2: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress. Modifiers like good could be more specific, and all options must have a time frame for evaluating the desired performance.

Rationale 3: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress, and all options must have a time frame for evaluating the desired performance.

Rationale 4: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress, and all options must have a time frame for evaluating the desired performance. This option includes all necessary components.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Identify guidelines for writing goals/desired outcomes.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 197

Question 10

Type: MCSA

The nurse is reviewing the Nursing Outcomes Classification (NOC) taxonomy system. To what can the nurse compare this taxonomy?

1. Nursing diagnosis statement

2. Planning portion of the care plan

3. Goal statement of the traditional care plan

4. Implementation phase of the care plan

Correct Answer: 3

Rationale 1: The nursing diagnosis statement must follow the NANDA format.

Rationale 2: Goal setting is part of the planning, but the NOC outcome is narrower in use than general planning.

Rationale 3: The Nursing Outcomes Classification (NOC) describes client outcomes that respond to nursing interventions seen in traditional care plans.

Rationale 4: Implementation is compared to the Nursing Interventions Classification (NIC) taxonomy.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6. Discuss the Nursing Outcomes Classification, including an explanation of how to use the outcomes and indicators in care planning.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 197

Question 11

Type: MCSA

The nurse is caring for a client with Parkinsons disease who desires to improve fine motor skills. Which statement should the nurse identify as an appropriate collaborative intervention for this client?

1. Provide assistance as needed with dressing and grooming.

2. Provide assistive devices and educate client to use grab bar and large handled utensils.

3. Make sure lighting and space are adequate for client.

4. Administer medications to improve muscle tone.

Correct Answer: 2

Rationale 1: Providing assistance and attending to the clients space would be independent interventions.

Rationale 2: Collaborative interventions are actions the nurse carries out with other health team members, such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships between, health personnel. Providing assistive devices and educating on their proper use would fall into the discipline of physical/occupational therapy, although the nurse will have to assist with reinforcing the teaching and information.

Rationale 3: Collaborative interventions are actions the nurse carries out with other health team members, such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships between, health personnel. Attending to the clients space would be an independent intervention.

Rationale 4: Administering medications would be a dependent intervention.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 201

Question 12

Type: MCSA

The nurse is reviewing interventions written for a clients plan of care. Which intervention should the nurse recognize as being dependent?

1. Repositioning the client every 2 hours

2. Assisting the client with transfers to the bathroom

3. Providing ongoing physical assessment, especially of the incisional sites

4. Administering medications for pain

Correct Answer: 4

Rationale 1: This is an example of an independent intervention: those activities that the nurse is licensed to initiate on the basis of knowledge and skills.

Rationale 2: This is an example of an independent intervention: those activities that the nurse is licensed to initiate on the basis of knowledge and skills.

Rationale 3: This is an example of an independent intervention: those activities that the nurse is licensed to initiate on the basis of knowledge and skills.

Rationale 4: Dependent interventions are those activities carried out under the physicians orders or supervision or according to specified routines. The nurse is responsible for assessing the need for and administering medications, but the physician prescribes them.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 201

Question 13

Type: MCSA

One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. What should the nurse identify as the modifier in this intervention?

1. 60 to 90 degrees during feeding times

2. Position in chair

3. Upright in a chair

4. Impaired swallowing

Correct Answer: 1

Rationale 1: Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. In this case, defining upright as 60 to 90 degrees and during feeding times gives when this should be done.

Rationale 2: The word position is not descriptive enough for modifiers.

Rationale 3: The word upright is not descriptive enough for modifiers.

Rationale 4: Impaired swallowing is the NANDA label.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 198


Question 14

Type: MCSA

A nurse is caring for a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Which should the nurse identify as an observation intervention?

1. Turn and reposition client every 2 hours.

2. Cushion bony prominences with soft foam while in bed.

3. Provide ongoing assessment for skin breakdown every shift.

4. Apply lotion to dry skin twice daily.

Correct Answer: 3

Rationale 1: Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Turning and repositioning would help prevent any further skin breakdown.

Rationale 2: Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Cushioning bony prominences would help prevent any further skin breakdown.

Rationale 3: Observations include assessments made to determine whether a complication is developing as well as observations of the clients responses to nursing and other therapies. Assessment for skin breakdown would fall under this category.

Rationale 4: Application of lotion or other treatments to areas of skin impairment would be considered a treatment intervention.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 202

Question 15

Type: MCSA

The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most appropriate manner for the nurse to write this intervention?

1. Assist client with ambulation.

2. Ambulate with client, using a gait belt, twice daily for 15 minutes.

3. Make sure client understands the rationale for using the gait belt.

4. Client will ambulate in hallway twice daily.

Correct Answer: 2

Rationale 1: This option lacks some of the required components of a wellwritten intervention.

Rationale 2: A well-written intervention should include a verb, conditions, and modifiers, plus a time element. Identifying what to do (ambulate), how to do it (with a gait belt), and how long (twice daily for 15 minutes) is the most precise statement.

Rationale 3: This option lacks some of the required components of a wellwritten intervention.

Rationale 4: Client will ambulate in the hallway is a goal statement, not an intervention.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 201

Question 16

Type: MCSA

A hospital is implementing the use of the NIC (Nursing Interventions Classification) taxonomy. What purpose will the implementation of this taxonomy serve?

1. Help the nurse with documentation of the care plan

2. Require that the nurse use sound judgment and knowledge of the client

3. Match nursing diagnoses to exact interventions

4. Help the nurse choose activities that are individualized to the client

Correct Answer: 2

Rationale 1: The NIC taxonomy may or may not help with documentation.

Rationale 2: The NIC taxonomy, like NOC, is similar to NANDA diagnosesbroadly stated interventions that are standardized in language and generalized in nature. Each nursing diagnosis contains suggestions for several interventions under the NIC taxonomy, and nurses must select the appropriate interventions based on their judgment and knowledge of the client.

Rationale 3: Although it would utilize standard language for all nurses and offer suggestions of interventions for each diagnosis, finding the most appropriate interventions still requires individualization for each client.

Rationale 4: This taxonomy is general and standardized and must be tailored to fit the needs, outcomes, and goals of the individual client.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10. Discuss the Nursing Interventions Classification, including an explanation of how to use the interventions and activities in care planning.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 202

Question 17

Type: MCSA

The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale?

1. Have suction equipment available at all times.

2. Clear secretions from oral/nasal passageways as needed.

3. Keep client in low-Fowlers position to prevent reflux.

4. Provide frequent assessment for presence of obstructive material in mouth and throat.

Correct Answer: 3

Rationale 1: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain why an intervention would be implemented. This intervention does not explain why it is being done.

Rationale 2: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain why an intervention would be implemented. This intervention does not explain why it is being done.

Rationale 3: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain why an intervention would be implemented. Keeping the client in a position with the head elevated 30 to 45 degrees helps prevent the risk of reflux (food/liquids returning up through the esophagus after having been swallowed).

Rationale 4: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain why an intervention would be implemented. This intervention does not explain why it is being done.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 192

Question 18

Type: MCMA

The nurse manager is implementing computerized care plans for the care area. Which guidelines should the manager emphasize when the staff is writing care plans?

Standard Text: Select all that apply.

1. Plans must be dated and signed.

2. Categories must have headings.

3. Plans must be specific.

4. Plans must include preventive care and health maintenance.

5. Plans must include interventions for ongoing assessment.

6. Plans are standardized and generalized for all clients.

Correct Answer: 1, 2, 3, 4, 5

Rationale 1: This is a recognized guideline when writing care plans.

Rationale 2: This is a recognized guideline when writing care plans.

Rationale 3: This is a recognized guideline when writing care plans.

Rationale 4: This is a recognized guideline when writing care plans.

Rationale 5: This is a recognized guideline when writing care plans.

Rationale 6: Care plans are not both standardized and generalized for all clients.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Identify essential guidelines for writing nursing care plans.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 194

Question 19

Type: MCMA

The nursing staff is reviewing standards of care, standardized care plans, protocols, policies, and procedures for a multi-system health care facility. Why are these documents important to the nursing staff when providing client care?

Standard Text: Select all that apply.

1. To make sure all clients have the same type of care

2. To ensure that minimally accepted standards of care are met

3. To promote efficient use of the nurses time

4. To eliminate care disparities among clients

5. To minimize health care costs

Correct Answer: 2, 3

Rationale 1: Although standardized approaches to care planning are common in many health care agencies, ensuring that all clients receive the same type of care is not appropriate, as care must be individualized to meet the clients needs.

Rationale 2: Ensuring that minimally accepted standards of care are met is a reason for the actions mentioned in the scenario.

Rationale 3: Ensuring that nurses time is used efficiently is a reason for the actions mentioned in the scenario.

Rationale 4: Not all clients require the same care, and so disparities are not a concern.

Rationale 5: Although cost containment is important, it is not the focus of standardized approaches to care planning.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Explain how standards of care and pre-developed care plans can be individualized and used in creating a comprehensive nursing care plan.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 190

Question 20

Type: MCMA

The nurse is devising a care plan for a client with complex health issues and current acute health problems. Which criteria should the nurse ensure is used when planning interventions for this client?

Standard Text: Select all that apply.

1. Congruent with the clients values, beliefs, and culture

2. Are within established standards of care

3. Based on scientific and medical knowledge

4. Achievable with the resources available

5. Must be safe and appropriate for the clients age

Correct Answer: 1, 2, 4, 5

Rationale 1: This is a recognized guideline.

Rationale 2: This is a recognized guideline.

Rationale 3: The plan must be based on nursing knowledge and experience or knowledge from relevant sciences (based on rationale).

Rationale 4: This is a recognized guideline.

Rationale 5: This is a recognized guideline.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Describe the process of selecting and choosing nursing interventions.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 201

Question 21

Type: MCMA

The nurse is reviewing a clients plan of care. Which statements indicate that this care plan has been completed accurately and appropriately?

Standard Text: Select all that apply.

1. Ineffective coping related to drug abuse as evidenced by drug overdose.

2. The client will identify two healthy coping mechanisms by time of discharge.

3. The client has identified two health coping mechanisms to replace inappropriate drug use.

4. The client will be provided with guidance in identifying healthy coping mechanisms.

5. The client has apologized to his family for drug abuse behaviors.

Correct Answer: 1, 2, 3, 4

Rationale 1: The care plan is often organized into sections that include nursing diagnoses.

Rationale 2: The care plan is often organized into sections that include goals/outcomes.

Rationale 3: The care plan is often organized into sections that include evaluations.

Rationale 4: The care plan is often organized into sections that include nursing interventions.

Rationale 5: Although this might be a desirable behavior, it is not written as a goal.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 4. Identify essential guidelines for writing nursing care plans.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 198

Question 22

Type: MCMA

The nurse attends an educational program that provides information about the Nursing Intervention Classifications (NIC) system. Which statements made by the nurse indicate that teaching has been effective?

Standard Text: Select all that apply.

1. I can look up interventions according to the nursing diagnosis that Ive selected.

2. The interventions connected to a diagnosis are appropriate for any client with that diagnosis.

3. If there is a NANDA diagnosis, I should be able to find some appropriate interventions.

4. Care plans are best written when the interventions are broad and flexible.

5. I find NIC interventions a really good place to start when Im working on client interventions.

Correct Answer: 1, 3, 5

Rationale 1: The nurse can look up a clients nursing diagnosis to see which nursing interventions are suggested.

Rationale 2: Each nursing diagnosis contains suggestions for several interventions, so nurses need to select the appropriate interventions based on their judgment and knowledge of the client.

Rationale 3: All NIC interventions have been linked to NANDA nursing diagnostic labels.

Rationale 4: When writing individualized nursing interventions on a care plan, the nurse should record customized activities rather than broad intervention labels.

Rationale 5: Not all activities suggested for the intervention would be needed for every client, so the nurse chooses the activities appropriate for the client and individualizes them to fit the supplies, equipment, and other resources available in the agency.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 10. Discuss the Nursing Interventions Classification, including an explanation of how to use the interventions and activities in care planning.

MNL Learning Outcome: 1.4.2. Implement the diagnostic and planning phases of the nursing process.

Page Number: 202

New Questions:

Question 23

Type: MCMA

The nurse is collecting information to plan care for a client with a heart problem. Which information indicates that planning for this clients discharge was started by the nurse?

Standard Text: Select all that apply.

1. The client is scheduled for cardiac catheterization and echocardiogram.

2. Recent laboratory data indicates the development of heart failure.

3. The client does not have a scale to perform daily weights at home.

4. The clients spouse has care needs that the client will not be able to complete going forward.

5. The client is pleasant and eager to learn how to control newly diagnosed health problem.

Correct Answer: 3, 4

Rationale 1: The clients current treatment plan is not a part of discharge planning.

Rationale 2: The clients current health status is not a part of discharge planning.

Rationale 3: Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the clients ongoing needs. The lack of a scale at home for daily weights indicates that the nurse is planning ahead for the clients needs once discharged.

Rationale 4: Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the clients ongoing needs. Concern about the clients activity level at home indicates planning ahead for the clients needs once discharged.

Rationale 5: The clients personality and desire to learn more about the health problem is not a part of discharge planning.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: III. 6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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