Online Practice Test 13

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 13 > NCLEX® Review Date/Time Submitted: July 8, 2012 at 2:46 PM (UTC/GMT)

Summary of Results 50% Correct of 10 Scored items: 5 Correct:  50% 5 Incorrect:  50% More information about scoring

1.		The nurse is caring for a 28-year-old client who had ileostomy surgery two days ago. Which of the following client goals is correctly written? Your Answer: The client will demonstrate how to change the stoma appliance correctly by 9/1/07.
		Objective: State the purposes of establishing client goals/desired outcomes. Rationale: An appropriate goal will have a subject (the client), verb (action), conditioners or modifiers, and criterion of performance (standard by which the outcome is evaluated). Goals are stated in client terms-that is, what the client will do or achieve. Answer 2 does not have a clear standard that the nurse can use to determine if the client has achieved the goal. Answer 4 incorporates two goals into one goal statement and does not have measurable outcomes. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		What is the problem with the following outcome goal: "Client will state that pain is less than or equal to 2 on a 0 to 10 pain scale."  Your Answer: It does not have a condition or measure. Correct Answer: There is no criterion for performance.
		Objective: Describe the relationship of goals/desired outcomes to the nursing diagnoses. Rationale: Proper goal statements will have the subject (the client), the verb (action), conditions or modifiers, and standard of performance. There is no time frame by which the goal achievement can be measured. For example, the time frame may be stated as "by 48 hours after surgery". The condition or measure in this case is pain that is less than or equal to 2 on a 0 to 10 pain scale. In Answer 3, the client action (behavior) is "will state". In Answer 4, the goal lacks a criterion (time) by which the nurse can measure goal achievement. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		Suppose a desired outcome statement is poorly written. What effect, if any, will it have on client care? Your Answer: The planned interventions may be incorrect.
		Objective: State the purposes of establishing client goals/desired outcomes. Rationale: Properly written outcome statements are the link between diagnoses and nursing interventions. Poorly written outcome statements affect the planned interventions. The interventions cannot be properly planned or implemented with poorly written goals. The nurse will have already begun implementing the care plan that will have been improperly planned. For example, a time frame for evaluation may be missing, thus slowing the rate at which interventions are carried out. The outcomes/goals are based on diagnoses, so they are not affected by a poorly written outcome. The assessments serve as the basis for diagnoses and outcomes/goals. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection
4.		Assessment of a client two days after surgery reveals a dressing that is dry and intact, temperature 100.2, pulse 90, and blood glucose level of 428. The client requests additional juice or water due to a very dry mouth, and says he is feeling weak and having pain with ambulation. Which of the following is the nurse likely to consider the highest priority for a change in the plan of care?  Your Answer: Pain Correct Answer: Elevated blood sugar
		Objective: Identify factors that the nurse must consider when setting priorities. Rationale: Urgency determines the priority in planning care. In this case, the blood sugar is very high, and needs immediate intervention. Pain will need to be addressed, but other symptoms the client is experiencing may abate once the blood sugar is in normal range. A slightly elevated temperature is considered normal after surgery, and with a dressing that is dry and intact, the possibility of infection is not of the highest priority. There is no indication of the severity of the pain. The nurse will want to further assess pain after the blood sugar is regulated. Dry mouth is likely a sign of an elevated blood sugar. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Decide what the best action is for client and situation.
5.		What is wrong with the following nursing order: "9/1/07. Encourage fluids as desired. T. Smith, RN." Your Answer: It is unrealistic. Correct Answer: It is not individualized.
		Objective: List the five components of a nursing order. Rationale: Nursing orders are instructions the nurse gives for the specific individualized activities the nurse performs to help the client meet goals/outcomes. When fluids are appropriate, it is up to the nurse to determine how to plan fluid intake to help the client achieve the stated goal/outcome. The goal cannot be evaluated for how realistic it is without further information about how much fluid or how often the fluid should be taken and knowledge of the client's overall condition. It is not written as a preventive order. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Decide what the best action is for client and situation.
6.		Consider the following nursing diagnosis for a client who is on bed rest: Risk for Impaired Skin Integrity related to bed rest. Which of the following nursing interventions was derived from the etiological portion of the nursing diagnosis? Your Answer: Turn and reposition q 2h.
		Objective: Discuss the Nursing Interventions Classification, including an explanation of how to use the interventions and activities in care planning. Rationale: Nursing interventions must be individualized, and should focus on eliminating or reducing the etiology of the nursing diagnosis. Bed rest is the etiology and requires the client to move or be repositioned at least q 2h. Foods high in protein will not counteract the effects of bed rest. A bath is important for the client's well-being and for assessing the skin, but it is not related to the etiology of the nursing diagnosis. Offering a back rub PRN is important, but it is not related to the etiology of the nursing diagnosis. It does not reduce or eliminate the etiology of the diagnosis. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Decide what is the best action for client and situation.
7.		A client has a nursing diagnosis of Bathing/Hygiene Self-Care Deficit related to left-sided weakness manifested by inability to get in and out of the bathroom, inability to wash hands or face, and fatigue. An appropriate goal for this client would be that the client: Your Answer: Demonstrate an ability to wash face independently by 9/1/07
		Objective: Identify guidelines for writing goals/desired outcomes. Rationale: Goals are written in terms of client responses, not nurse activities. Goals must be realistic and compatible with therapies (if prescribed). The goals should flow from the nursing diagnoses and be measurable. Answer 1 is not measurable; therefore, it is not appropriate. Have a nursing assistant bathe the client once daily is what the nurse will do; it is not stated in client terms. Answer 4 is a client activity, but it does not have a measurable outcome for the nurse to evaluate. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Physiologic needs come first then safety. Psychosocial needs are addressed after physiologic and safety.
8.		An agency might have a standard of care for which of the following? Your Answer: Have laboratory obtain blood glucose if bedside blood glucose exceeds 400 Correct Answer: Congestive heart failure
		Objective: Explain how standards of care and preprinted care plans can be individualized and used in creating a comprehensive nursing care plan. Rationale: Standards of care describe nursing actions for clients with specific medical conditions and describe achievable, appropriate nursing care. Congestive heart failure is a medical condition, and many patients with this diagnosis have similar interventions that would be appropriate. Answer 1 is an example of a policy and procedure, not a medical condition. Deficient Fluid Volume is an example of a standardized care plan based on a nursing diagnosis, not a standard of care that refers to a medical problem. Answer 4 is an example of a policy and procedure or, depending on the agency, a protocol. It is not a standard of care. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
9.		The nurse who is developing an initial plan of care for a client will expect to include on it: Your Answer: Admission vital signs Correct Answer: A nursing diagnosis
		Objective: Identify essential guidelines for writing nursing care plans. Rationale: The initial plan of care typically is completed immediately after the admission assessment. It includes nursing diagnoses, goals or outcomes, and interventions that assist the client to achieve the goals or outcomes. The vital signs are part of the database that serves as the basis for the initial care plan, but are not part of the care plan itself. Requests are not part of the care plan. The list of medications the client takes at home is part of the database that serves as the basis for the initial care plan, but is not part of the care plan itself. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Read question and prioritize nursing actions.
10.		The broad goal for the client is to ambulate independently. Which of the following is a correctly written desired outcome? Your Answer: The client will ambulate to the bathroom without a walker by 9/1/07.
		Objective: State the purposes of establishing client goals/desired outcomes. Rationale: Broad goals are usually not sufficiently clear and specific enough to guide the nurse in carrying out daily interventions. A broad goal needs many smaller, more specific and measurable goals that help the client achieve the broad goal. The client will walk the length of the hall is measurable in terms of distance, but does not have a time frame by which the outcome can be evaluated. The client will demonstrate how to dangle from the side of the bed by 9/1/07 is not an activity the client would perform to ambulate independently. Use a gait belt when assisting the client to ambulate in the hall is a nursing intervention, not an outcome. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Decide what is the best action for client and situation.