Nursing Care Plan and Management: A Guide to Best Practice, 4th Edition, by Joyce M. Black, Barbara L. Hawks, and Marlene C. Keene
This comprehensive nursing care plan and management guide, now in its 4th edition, is a must-have resource for students and nurses alike. Packed with evidence-based strategies, this book provides you with the tools you need to develop effective nursing care plans, manage patient care effectively, and provide optimal patient outcomes.
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Western Governors University NURSING UG C229 Leadership Questions and Answers Rated AA 13-year-old female client tells the charge nurse in the pediatric unit that she does not want a male nurse assigned to care for her. Which of the following is the nurse's best response? "I'll change the assignment so a female nurse is caring for you today." - The client has the right to participate in decisions regarding her care. It is not unusual for an adolescent client to be uncomfortable being cared for by a nurse of the opposite sex. Whenever it is feasible, a request such as this should be respected and honored. An 18-year-old client in remission with rhabdomyosarcoma has just been diagnosed with metastasis to the bone. The client says that he does not want to have chemotherapy again. Which of the following statements is consistent with the client's rights? The nurse states, "I can gather information about palliative care for you." - The nurse is acknowledging the client's right to refuse treatment and is demonstrating support by offering to discuss end-of-life care options. After a disaster plan is put into effect, a nurse in a pediatric unit is asked to prepare a list of clients who can be discharged to home due to a local incident involving many child victims. Which of the following clients should the nurse place on the potential discharge list? - A preschooler who has asthma and has scattered wheezes with PRN use of abuterol - A school age child who has a femur fraction in an external fixation device and whose pain is controlled with PRN oral codeine - A developmentally delayed adolescent client who has osteomyelitis, has a PICC line, and needs 6 more weeks of antibiotics A preschooler who has asthma and has scattered wheezes that resolve with PRN use of albuterol (Proventil) is correct. The nurse should place clients who can be both quickly and safely discharged on the potential discharge list. Children who have asthma are most often managed at home once the acute phase of illness has resolved. Because this client's manifestations are responsive to the prescribed medication, this child should do well at home with appropriate discharge teaching and if follow-up care is planned. A school-age child who has a femur fracture in an external fixation device and whose pain is controlled with PRN oral codeine is correct. The nurse should place clients who can be both quickly and safely discharged on the potential discharge list. External fixation devices are worn for weeks to months: they are most often managed at home once the device is placed and the client has learned how to care for the immobilized limb. This client's pain is responsive to oral codeine. Prior to discharge, the client may need instructions on ambulation and weight-bearing, as prescribed. A developmentally delayed adolescent client who has osteomyelitis, has a PICC line, and needs 6 more weeks of antibiotics is correct. The nurse should place clients who can be both quickly and safely discharged on the potential discharge list. Long-term antibiotic therapy is typically completed in the home following PICC line placement. A visiting nurse can assist this client in home care management. The client's developmental delay has no bearing on whether the client is safe to discharge. An infant who has non-organic failure to thrive, has gained weight since hospitalization, and may be discharged to foster care is incorrect. The nurse should place clients who can be both quickly and safely discharged on the potential discharge list. This client's discharge plan is not certain. Note that the option states that the client may be discharged to f t Thi i t th t f it ti th t i t i ll id d i k t h dl i i i t di t it ti Based on recommendations following a regulatory agency visit, the nurse manager mandates a policy change. One of the staff members on the unit is resistant to the change Encourage the nurse to verbalize reasons for resisting the change A charge nurse in an emergency department is making assignments for an assistive personnel for a shift with unexpected staff absences. Escort clients from the emergency department to other areas of the facility for tests A charge nurse is delegating tasks on a nursing unit that is short staffed. A client has a prescription for a wound irrigation twice a day. Which of the following actions should the charge nurse take? Assign the procedure to a licensed practical nurse (LPN). - This task is within the scope of practice of an LPN. The charge nurse should delegate this task to the LPN. A charge nurse is discussing issues with a staff nurse. When evaluating statements by the staff nurse, the charge nurse should recognize that which of the following reflects an intrapersonal conflict? "I'm not sure whether I want to apply for the unit manager's position or start a family this year." - The nurse's statement indicates an intrapersonal conflict because the nurse is struggling with competing personal and professional values and desires. A charge nurse is evaluating conflict resolution between two staff nurses Accommodation A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next? Determine goals and objectives. - According to evidence-based practice, the nurse attempting to make a change or revision to a policy should first develop the initial plan and then determine goals and objectives. Objectives define strategies or implementation steps to attain the identified goals. A charge nurse is making assignments for an oncoming shift. Which of the following clients should the charge nurse assign to a LPN? A client who is disoriented and awaiting transfer to a long term care facility A charge nurse is managing conflict with a staff nurse who does not agree with the client assignment. Which of the following statements is an example of using the conflict resolution strategy known as smoothing? "You always complete your work on time and do a great job. I believe you can handle the assignment well." - The charge nurse is using smoothing as a conflict resolution strategy by complimenting or focusing on shared ideas to reduce the emotional component of the conflict. A charge nurse is observing a group of newly licensed nurses. Which of the following observations should the charge nurse report to the nurse manager as a violation of HIPAA? Talking about clients with other nurses in the cafeteria A charge nurse is observing a newly licensed nurse's use of time management skills. Which of the following actions by the newly licensed nurse indicates effective use of this skill? Groups tasks that are in the same location - The newly licensed nurse should group tasks that are in the same location to effectively use her time. This prevents the nurse from going back and forth from one area to another. This action promotes effective time-management skills. A charge nurse is observing a nurse perform a sterile dressing change for a client. Which of the following actions should the charge nurse identify as appropriate sterile technique? The nurse places the sterile package with the top flap opening away from her. - The nurse should place the sterile package on a flat surface so that the top flap opens away from her. This prevents the contents of the sterile package from becoming contaminated. A charge nurse is orienting a newly licensed nurse to the facility's policies regarding electronic medical records. Which of the following statements by the newly licensed nurse indicates an understanding of the instructions? "After I finish with the printout of my assignment, I'll put it in the shredder receptacle." - The nurse should shred all computer printouts and worksheets that contain clients' protected health information to maintain client confidentiality. A charge nurse is providing orientation to a new staff nurse regarding the management of a team consisting of a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following instructions by the charge nurse regarding care of a group of clients may result in unsafe practice? The accountability for a task is assumed by the person to whom it is delegated. - This is an incorrect instruction given by the nurse manager that may result in unsafe practice. While responsibility for a task can be delegated, accountability for any delegated task remains with the nurse who delegated the task. TEST-TAKING STRATEGY: This question has a false-response stem; the question is asking for an instruction that may result in an unsafe practice. A charge nurse is supervising the care of several clients. Which of the following actions requires intervention by the charge nurse? A student nurse is photocopying his assigned client's diagnostic test results. - Photocopying diagnostic test results is a breach of the client's confidentiality and privacy. A charge nurse on a medical-surgical unit is planning care for a client who has dementia and is being admitted for surgery. Which of the following would promote safety when caring for this client? Placing the client in a room near the nurses' station. - The nurse should place the client in a room near the nurses' station and observe the client frequently to reduce the risk of injury. A charge nurse on a pediatric unit is delegating tasks to an assistive personnel who is pregnant and reports that she is unsure of her immune status A 2 year old child who has impetigo contagiosa A charge nurse receives a call from his nursing supervisor about an explosion at a local factory and an urgent need for facility beds a 44 year old client who has asthma and admitted for carpal tunnel surgery A charge nurse recognizes a trend of poor attendance at monthly staff meetings. To address this issue, which of the following actions should the charge nurse take first? Explore the reasons that staff are not attending the meetings. - According to evidence-based practice the nurse should first identify the reasons that staff are not attending the meetings. A client has Alzheimer's, refuses to take antihypertensive medication, is oriented to time and place, and is able to perform ADLs with minimal supervision. What action should the nurse take? a. crush pills and feed them to client in applesauce b. insist client comply by informing her of possible implications of missing a dose c. notify the provider of need for further evaluation of client's level of competence d. ask client to express her reasons for refusing the medication and document the event d. ask client to express her reasons for refusing the medication and document the event A client in a long term care facility falls out of bed, fracturing his left hip. The side rails on the bed were not raised at bedtime Negligence A client is being transferred to the surgical suite for a procedure when the client suddenly exclaims, "I've changed my mind. I don't want to go through with this!" Which of the following is an appropriate response by the nurse? "Let me call your surgeon while you tell me about your concerns." - This is an appropriate response because the client has the right to refuse treatment. Speaking with the nurse and the provider about concerns or questions may allay anxieties and allow the client to continue with the procedure. Consent may be withdrawn after it's given and clients have the right to change their minds. It is the nurse's responsibility to notify the surgeon if the client verbalizes a desire to stop or delay a medical procedure or treatment. A client is considering having a tubal ligation, and she tells the nurse that she is uncertain if it is the right thing to do. Which of the following is an appropriate response by the nurse? Discuss the client's feelings about the procedure. The nurse cares for a client diagnosed with superficial partial thickness burn. The nurse should assign the client to a room with which client? - ANSWER A client diagnosed with Cushing's Syndrome. The nurse observes client care on a geriatric unit. The nurse should intervene in which situation? - ANSWER A student nurse assists the client to stand from a sitting position by grasping the client's elbows. The nurse evaluates the results of the client's purified protein derivative (PPD) 2 1⁄2 days after the injection. The nurse noted the induration is 4 mm. which action by the nurse is most appropriate? - ANSWER Inform the client the results are negative The nurse cores for the client with a history of schizophrenia. The nurse expects to note which speech pattern? - ANSWER Repetition of the words used by the nurse. The nurse cares for a 6-month-old infant. The parents report that the infant had severe diarrhea for twelve hours. The nurse anticipates which finding? - ANSWER Depresses anterior fontanel. The nurse cares for a client receiving hydrocodone every 6 hours prn for pain. The client reports pain at 1600. The nurse notes that the hydrocodone was last administered at 1200, and the nurse proceeds to administer hydromorphone at 1615. After discovering the error, how should the nurse record the occurrence? - ANSWER Hydromorphone given at 1615; health care provider notified. B/P 122/80, RR 16." The male client asks the nurse, "Why am I experiencing erectile dysfunction (ED)?" The nurse reviews the client's medications. The nurse recognizes that which classification increases the risk for ED? - ANSWER Antihypertensive medications. The nurse in the hospital cafeteria overhears two nursing assistive personnel (NAP) discuss the client's condition. What is the PRIORITY action for the nurse to take? - ANSWER Inform the employees about patient confidentiality and the client's right to privacy. The nurse cares for a client diagnosed with dehydration. The plan of care indicates the client is to drink two ounces of fluid every hour. The nurse determines the goal is met if which is recorded on the intake and output (I&O) sheet for an eight-hour shift? - ANSWER 480 ml The nurse and LPN/LVN care for clients on a medical-surgical unit. The RN should delegate which activity to the LPN/LVN? - ANSWER Take the blood pressure and heart rate before administration of enalapril. The nurses care for the client diagnosed with tuberculosis. Before discontinuing airborne precautions, the nurse must confirm which? - ANSWER No acid-fast bacteria are in the sputum. The nurse cares for the client at 28 weeks gestation diagnosed with a complete placenta previa. The nurse determines discharge teaching is effective if the client makes which statement to her husband? - ANSWER I'm sorry to tell you we can't have sexual relations The nurse prepares the client diagnosed with myxedema for discharge. Which action should the nurse teach related to body temperature? - ANSWER "Put on multiple layers of clothes until you fell comfortably warm." The nurse cares for clients in the labor and delivery unit. The nurse anticipates which client is a candidate for induction of labor? - ANSWER The client diagnosed with preeclampsia. The nurse cares for the client diagnosed with HIV. The nurse determines which goal is MOST important? - ANSWER Prevent infections. The nurse educator presents an in-service on acyanotic heart disease. Which is the most common symptom of this disorder that the nurse educator should include? - ANSWER Presence of an audible heart murmur. The nurse provides care for the client diagnosed with pneumonia who has postural drainage twice a day. Which client response indicates to the nurse that treatment is effective? - ANSWER "I am coughing up more sputum." The risk management department plans a program to reduce errors. Which is the most common cause of errors in medication administration? - ANSWER Failure to follow routine policy and procedures. The nurse cares for the school-aged child newly diagnosed with type 1 diabetes. The nurse instructs the family that the child's insulin needs will decrease during which situation? - ANSWER Active exercise The nurse cares for the client receiving lactulose. The nurse determines the medication is effective if which is observed? - ANSWER The client is alert and oriented to person, place and time. The nurse cares for the three-year-old prior to a surgical procedure. Which behavior indicates that the child is coping with preoperative preparation? - ANSWER The child talks about the picture of a nurse and client while coloring the picture using a number of bright colored crayons. The nurse instructs the client after a total hip arthroplasty. The client will utilize which assistive devices in the home? - ANSWER SATA: A long-handled shoehorn. A reaching device. A raised toilet seat. A shower bench. The client reports vomiting and diarrhea for three days. Which assessment finding does the nurse anticipate? - ANSWER Decreased blood pressure. The nurse cares for the client in active labor. The health care provider orders an oxytocin infusion. Which action should the nurse take FIRST after initiating the infusion? - ANSWER Time and record the length and strength of the contractions. The intensive care nurse cares for the client two hours after a myocardial infarction is diagnosed. The nurse's PRIORITY is to focus on which action? - ANSWER Relieve pain. The home health nurse instructs the family how to "allergy-proof" their preschooler's bedroom. The nurse determines teaching is successful if which of the following is observed? - ANSWER There are no pictures hung on the walls. The nurse cares for infants in the newborn nursery. Which observation requires the nurse to contact the physician? - ANSWER Uneven skin folds are noted on a the upper legs of a Mexican-American female born 6 hours ago. The nurse cares for the client diagnosed with partial thickness burns to the entirety of both arms. Using the Rule-of-Nines, the nurse estimates the injury is which percentage? - ANSWER 18% The home care nurse visits the client diagnosed with late stage Parkinson's disease. The client sits in a wheelchair. Which statement, if made by the caretaker, indicates to the home care nurse teaching is effective? - ANSWER "My Client should push the hips up from the wheelchair for about 10 seconds every hour or so." The home care nurse makes a visit to the client diagnosed with heart failure. The client reports having difficulty sleeping at times. The nurse should take which action FIRST? - ANSWER Obtain a thorough sleep assessment history. The nurse cares for the client admitted to the critical care unit. The nurse observes splinter hemorrhages in the nails, painful nodules on the fingertips and splenomegaly. It is MOST important for the nurse to take which action? - ANSWER Auscultate the precordium for murmurs. (ENDOCARDITIS) The nurse instructs the client about stable angina. The nurse determines teaching is effective if the client makes which statement? - ANSWER My chest pain can occur if I overexert myself. The nurse cares for the client in pain. Which factor is MOST important to determine if the client is a candidate for patient controlled analgesia? - ANSWER The client is mentally alert. The nurse received report from the previous shift. Which client should the nurse see FIRST? - ANSWER The client scheduled for discharge later in the day and is reporting increased shortness of breath. The nurse reviews the arterial blood gas Nursing Care Plan and Management: A Guide to Best Practice, 4th Edition, by Joyce M. Black, Barbara L. Hawks, and Marlene C. Keene
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