Question 1

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?
A)Turn and reposition the patient every 2 hours.
B)Assess the patient's skin condition.
C)Change pressure injury dressings every shift.
D)Apply hydrocolloid dressing to the pressure injury.

Accepted Answer

Turning and repositioning the patient every 2 hours is a task that can be safely delegated to nursing assistive personnel (NAP) as it does not require the advanced skills or judgment of a registered nurse. Assessing the patient's skin condition, changing pressure injury dressings, and applying specific types of dressings are tasks that require the specialized knowledge and skills of a nurse.

Question 2

The nurse is providing care for a patient in an acute care facility. The nurse plans to evaluate the effectiveness of the plan of care. Which action does the nurse need to take to achieve a valid evaluation?
A)Read the documentation by the previous nurse.
B)Collect reassessment data on the patient.
C)Look at the physician's progression notes.
D)Ask the patient's view about each nursing goal.

Accepted Answer

To evaluate the effectiveness of the plan of care, the nurse needs to collect reassessment data on the patient to compare it with the initial data and determine if the goals have been met.

Question 3

Which statement by the registered nurse (RN) best demonstrates clear communication to nursing assistive personnel (NAP) about a delegated task?
A)"Record the patient's intake and output of fluids throughout the shift, please."
B)"Take the patient's temperature, pulse, respirations, and blood pressure every 2 hours today."
C)"Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)."
D)"Assist the patient with all meals so that the patient's intake of calories will increase."

Accepted Answer

C) provides a specific task (taking the patient's temperature every 4 hours) and clear instructions on what to do if a specific condition is met (if the temperature is greater than 100.5°F), demonstrating clear communication.

Question 4

The nurse receives a postsurgical patient who is prescribed to have vital signs taken every 15 minutes for 2 hours. Which type of client-centered evaluation does the nurse recognize?
A)Intermittent
B)Ongoing
C)Terminal
D)Process

Accepted Answer

The answer of The nurse receives a postsurgical patient who...

Question 5

The nurse reviews a patient's chart and sees a physician's prescription for a new medication. The nurse is able to clearly read the medication name, but the dose is not legible. Which is the best action by the nurse?
A)Contact the physician for clarification.
B)Ask another nurse to read the order.
C)Ask the unit secretary to read the order.
D)Contact the pharmacist to read the order.

Accepted Answer

The best action is to contact the physician for clarification to ensure the accuracy and safety of the medication dose. This direct approach eliminates the risk of misinterpretation and ensures the nurse administers the correct dosage as intended by the physician.

Question 6

The nurse is providing care for a client newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan?
A)Teaching the client that weight must be lost to control blood glucose
B)Informing the client it is necessary to exercise at least three times per week
C)Explaining to the client attendance is mandatory at the diabetic clinic weekly
D)Determining the client's main concerns about the diagnosis of diabetes

Accepted Answer

Determining the client's main concerns about the diagnosis of diabetes is the best approach to promote cooperation with the treatment plan. This intervention is client-centered, acknowledges the client's feelings and perspectives, and can help tailor the treatment plan to address specific concerns, thereby enhancing motivation and adherence.

Question 7

The nurse is delegating patient care to a nursing assistive personnel (NAP) with whom the nurse has worked before. The nurse provides exact details of which patient, what tasks, what time period, and what feedback is expected; the NAP has no questions. Which responsibility does the nurse retain after completing the delegation assignment?
A)The nurse will determine and evaluate completion of the assignment.
B)The nurse will check the NAP's progress on the assignment every hour.
C)The nurse will immediately document the assigned tasks as being delegated.
D)The nurse periodically checks the accuracy of the NAP's documentation.

Accepted Answer

The nurse retains the responsibility to determine and evaluate the completion of the assignment after delegating tasks to nursing assistive personnel (NAP). This includes ensuring that the tasks were completed correctly and in a timely manner, as well as assessing the outcomes of the delegated tasks.

Question 8

The nurse is providing care for a patient after joint replacement surgery. The standardized care plan states, "Patient will ambulate 50 feet in the hall with a walker before discharge." Which patient variable affecting this goal is the nurse unable to control?
A)Confusion and lethargy related to pain medication
B)Compromised respiratory function due to severe chronic obstructive pulmonary disease (COPD)
C)Reluctance to ambulate due to pain at level 7
D)Presence of a spouse who pushes the patient to rest

Accepted Answer

The nurse is unable to control compromised respiratory function due to severe chronic obstructive pulmonary disease (COPD) as it is a pre-existing medical condition that directly impacts the patient's physical ability to perform activities like ambulation.

Question 9

The nurse is assigned to participate in a structure evaluation for an acute care facility. Which response on the nurse's structure evaluation form indicates the nurse understood the criteria related to the task?
A)"Staff refrains from sharing computer passwords."
B)"Healthcare provider washes hands with each client contact."
C)"A defibrillator is present in each client care area."
D)"Nurses verify client identification before initiating care."

Accepted Answer

Structure evaluation focuses on the resources available in the healthcare setting, such as equipment and facilities. The presence of a defibrillator in each client care area is a structural aspect of the healthcare environment.

Question 10

A physician prescribes an indwelling urinary catheter for a client who is mildly confused and combative. In which manner does the nurse proceed?
A)Ask a colleague for help because the nurse cannot safely perform the procedure alone.
B)Gather and prepare the equipment before informing the client about the procedure.
C)Obtain a prescription to restrain the client before inserting the urinary catheter.
D)Inform the physician the nurse cannot perform the procedure because the client is confused.

Accepted Answer

The nurse should ask a colleague for help because the client is confused and combative, which could make the procedure unsafe to perform alone.

Question 11

After gathering and analyzing data and identifying patient needs, the nurse begins the implementation phase of developing a plan of care. Which is the best example of the implementation phase of the nursing process?
A)Patient verbalizes pain is reduced from 8 to 3 after receiving pain medication.
B)Nurse observes that patient has a small, quarter-sized skin tear over coccyx area.
C)Nurse writes in the care plan: Patient requires two-person assist with ambulation to bathroom.
D)Nurse inserts urinary catheter after reporting to physician the patient's inability to void.

Accepted Answer

The implementation phase of the nursing process involves putting the developed plan into action to achieve the goals set for patient care. Inserting a urinary catheter in response to a patient's inability to void is a direct action taken to address a patient need, fitting the definition of the implementation phase.

Question 12

The nurse works in an acute care facility, which implements team nursing with each team consisting of members from various levels of healthcare provision. Which statement accurately describes delegation in the nurse's work environment?
A)Transferring authority to perform a task to a qualified person in a selected situation
B)Collaborating with other caregivers to make decisions and plan patient care
C)Scheduling treatments and activities by coordinating with other departments
D)Implementing an appropriate planned intervention from a critical pathway

Accepted Answer

Delegation in nursing involves transferring the authority to perform a specific nursing task in a specific situation to a competent individual. This is distinct from collaboration (B), scheduling or coordinating treatments (C), or implementing care plans (D), which are other aspects of nursing practice but do not define delegation.

Question 13

A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, who cannot find it in the hospital formulary or other references. In which manner does the nurse proceed?
A)Administer the medication as ordered.
B)Hold the medication and notify the prescriber.
C)Consult with a pharmacist before administering it.
D)Ask the patient's registered nurse (RN) for information about the medication.

Accepted Answer

The nurse should consult with a pharmacist to obtain accurate information about the medication before administering it, ensuring patient safety and proper medication management.

Question 14

The nurse works with the respiratory therapist to administer a patient's breathing treatments. The therapist reports the patient's breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. Which type of implementation process is being used?
A)Delegation
B)Collaboration
C)Coordination of care
D)Supervision of care

Accepted Answer

The scenario describes collaboration, where the nurse and respiratory therapist work together to provide care, and the nurse communicates with the patient about treatment options.

Question 15

Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill?
A)Psychomotor
B)Interpersonal
C)Cognitive
D)Critical thinking

Accepted Answer

Reassuring the client involves communication and emotional support, which are key components of interpersonal skills. This type of skill is essential for building trust and rapport with the client.

Question 16

A second-year nursing student is in a clinical rotation on a medical-surgical unit. Which is the most appropriate strategy for the student to use to assist with organizing and prioritizing patient care for the day?
A)Ask the nurse what tasks need to be completed for the day.
B)Make a time-sequenced "to-do" list for care activities for the day.
C)Ask the instructor what needs to be completed for the day.
D)Ask the patient what needs to be completed for the day.

Accepted Answer

Making a time-sequenced "to-do" list for care activities for the day is an effective strategy for organizing and prioritizing patient care. This approach allows the student to visualize the tasks that need to be completed, prioritize them based on urgency and importance, and manage their time efficiently throughout the day.

Question 17

Which client outcome criterion does the nurse use when evaluating client behaviors that affect the client's health status?
A)Central venous catheter site infection does not occur in 90% of cases.
B)Client will sit in the bedside chair for 20 minutes three times per day.
C)Postoperative phlebitis does not occur in 95% of surgical patients.
D)Falls in the facility will be reduced by 2% at the end of the year.

Accepted Answer

B) Client will sit in the bedside chair for 20 minutes three times per day is a client-specific outcome that directly relates to evaluating behaviors affecting the client's health status. It is specific, measurable, and focused on the client's activity, which can impact their health recovery or maintenance. Choices A, C, and D are more related to general facility or population-based outcomes rather than individual client behaviors.

Question 18

The nurse creates a plan of care for a patient diagnosed with severe dehydration. One nursing goal reads, "Patient will maintain urine output of at least 30 mL/hour." Which time frame will the nurse use to collect evaluation data for this expected outcome?
A)At the end of the shift
B)Every 24 hours
C)Every 4 hours
D)Every hour

Accepted Answer

To evaluate the goal of maintaining a urine output of at least 30 mL/hour, the nurse would need to collect data every hour. This allows for timely adjustments to the care plan if the urine output falls below the expected outcome.

Question 19

The nurse reviews a nursing order for a patient who is 4 days postoperative after hip surgery, which reads: Assist patient in bathing each morning. The nurse assesses the patient and notes the patient demonstrates the ability to bathe independently. Which action does the nurse do next?
A)Assist with the bath, as ordered.
B)Delegate the bath to the nursing assistant.
C)Discontinue the nursing order on the plan of care.
D)Collaborate with the nurse who originally wrote the order.

Accepted Answer

The nurse should discontinue the nursing order on the plan of care because the patient is now able to bathe independently, making the order unnecessary.

Question 20

The certified nursing assistant (CNA) is feeding a patient and notices that the patient is having difficulty swallowing. The CNA reports the observation to the primary registered nurse. Which action does the nurse take first?
A)Assign the task to a more experienced can.
B)Continue patient feeding by the nurse.
C)Assess the patient, and place the patient on NPO (nothing by mouth) status.
D)Call the primary care provider.

Accepted Answer

The first action the nurse should take is to assess the patient and place them on NPO (nothing by mouth) status to prevent aspiration and further complications until a thorough assessment and appropriate interventions can be determined.

Quiz 7: Implementation Evaluation

The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP) ?

The nurse is providing care for a patient in an acute care facility. The nurse plans to evaluate the effectiveness of the plan of care. Which action does the nurse need to take to achieve a valid evaluation?

Which statement by the registered nurse (RN) best demonstrates clear communication to nursing assistive personnel (NAP) about a delegated task?

The nurse receives a postsurgical patient who is prescribed to have vital signs taken every 15 minutes for 2 hours. Which type of client-centered evaluation does the nurse recognize?

The nurse reviews a patient's chart and sees a physician's prescription for a new medication. The nurse is able to clearly read the medication name, but the dose is not legible. Which is the best action by the nurse?

The nurse is providing care for a client newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan?

The nurse is providing care for a patient after joint replacement surgery. The standardized care plan states, "Patient will ambulate 50 feet in the hall with a walker before discharge." Which patient variable affecting this goal is the nurse unable to control?

The nurse is assigned to participate in a structure evaluation for an acute care facility. Which response on the nurse's structure evaluation form indicates the nurse understood the criteria related to the task?

A physician prescribes an indwelling urinary catheter for a client who is mildly confused and combative. In which manner does the nurse proceed?

After gathering and analyzing data and identifying patient needs, the nurse begins the implementation phase of developing a plan of care. Which is the best example of the implementation phase of the nursing process?

The nurse works in an acute care facility, which implements team nursing with each team consisting of members from various levels of healthcare provision. Which statement accurately describes delegation in the nurse's work environment?

A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, who cannot find it in the hospital formulary or other references. In which manner does the nurse proceed?

Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill?

A second-year nursing student is in a clinical rotation on a medical-surgical unit. Which is the most appropriate strategy for the student to use to assist with organizing and prioritizing patient care for the day?

Which client outcome criterion does the nurse use when evaluating client behaviors that affect the client's health status?

The nurse creates a plan of care for a patient diagnosed with severe dehydration. One nursing goal reads, "Patient will maintain urine output of at least 30 mL/hour." Which time frame will the nurse use to collect evaluation data for this expected outcome?

The nurse reviews a nursing order for a patient who is 4 days postoperative after hip surgery, which reads: Assist patient in bathing each morning. The nurse assesses the patient and notes the patient demonstrates the ability to bathe independently. Which action does the nurse do next?

The certified nursing assistant (CNA) is feeding a patient and notices that the patient is having difficulty swallowing. The CNA reports the observation to the primary registered nurse. Which action does the nurse take first?