Ch 4 -The Nursing Process- Pharm

These flashcards summarize the key concepts and details of the nursing process as outlined in the lecture notes, aiding in exam preparation.

A client is admitted with a high fever. Which finding should the nurse document as objective data?

1. Client states, "I feel very warm."

2. Client reports a headache.

3. Oral temperature of 102.4^{\circ}\text{F}.

4. Client's mother says the client has been shivering.

Correct Answer: 3

Rationale: Objective data are measurable facts observed by the nurse, such as a temperature of 102.4^{\circ}\text{F}. Options 1, 2, and 4 are subjective data because they are personal reports from the client or family.

A nurse is preparing to administer an antihypertensive medication. The client's blood pressure is 90/50\text{ mmHg}. What is the nurse's priority action?

1. Administer the medication as ordered.

2. Withhold the drug and notify the healthcare provider.

3. Re-check the blood pressure in 2 hours.

4. Give the client a glass of water before the dose.

Correct Answer: 2

Rationale: If objective data reveals a significant change or safety concern (low blood pressure), the nurse must withhold the drug and contact the provider to prevent harm.

A nurse is developing a plan of care for a client who is confused about their new insulin regimen. Which nursing diagnosis is most appropriate?

1. Health Seeking Behavior

2. Ineffective Health Management

3. Deficient Knowledge

4. Anxiety

Correct Answer: 3

Rationale: Deficient Knowledge is used when the client lacks information or understanding regarding their treatment or drug regimen.

Which of the following is an example of a SMART expected outcome for a client learning to self-administer medication?

1. The client will know how to take pills.

2. The client will demonstrate correct injection technique by tomorrow morning.

3. The nurse will teach the client about side effects.

4. The client's health will improve eventually.

Correct Answer: 2

Rationale: SMART outcomes are Specific, Measurable, Achievable, Relevant, and Time-bound. Option 2 specifies an action (demonstrate technique) and a timeframe (tomorrow morning).

The nurse checks the client's medication administration record (MAR) against the drug label three times. Which of the 'six rights' is the nurse primarily ensuring?

1. Right Route
2. Right Patient
3. Right Drug
4. Right Documentation

Correct Answer: 3

Rationale: Comparing the MAR to the container label multiple times ensures the nurse is preparing the 'Right Drug'.

During an encounter, the nurse asks the client, "Has your pain decreased since you took the medication?" Which phase of the nursing process is the nurse performing?

1. Assessment
2. Implementation
3. Evaluation
4. Nursing Diagnosis

Correct Answer: 3

Rationale: Evaluation involves checking the effectiveness of the drug and determining if the client's symptoms have improved.

A nurse is documenting the administration of a PRN pain medication. When should this documentation occur?

1. Before the nurse prepares the medication.
2. At the end of the shift.
3. Immediately after the drug is administered.
4. Whenever the nurse has free time.

Correct Answer: 3

Rationale: 'Right Documentation' requires recording the administration immediately after the client receives the drug to maintain an accurate record.

Which nursing diagnosis would be most appropriate for a client who expresses concern about the cost and side effects of a new medication?

1. Deficient Knowledge
2. Anxiety
3. Ineffective Health Management
4. Altered Health Management

Correct Answer: 2

Rationale: Anxiety is an appropriate diagnosis when a client expresses worry or apprehension regarding their treatment or life changes related to drug therapy.

The nurse is performing an assessment on a new admission. Which of the following is considered subjective data?

1. The client's radial pulse is 72\text{ bpm}.
2. The client has a rash on their left arm.
3. The client states, "I feel dizzy when I stand up."
4. The client's weight is 150\text{ lbs}.

Correct Answer: 3

Rationale: Subjective data are reports or feelings provided by the client that cannot be directly measured by the nurse.

A nurse evaluates that a client has not met the expected outcome of lowering their cholesterol despite medication. What is the nurse's next step?

1. Tell the client they are failing the treatment.
2. Discharge the client from care.
3. Restart the nursing process to identify new interventions.
4. Double the dose of the medication.

Correct Answer: 3

Rationale: If expected outcomes are not met, the evaluation phase leads the nurse back to the beginning of the nursing process to re-assess and plan new strategies.

The nurse is checking that the dosage on the order matches the amount being prepared. Which 'right' is being addressed?

1. Right Time
2. Right Dose
3. Right Patient
4. Right Route

Correct Answer: 2

Rationale: 'Right Dose' ensures the nurse calculates and measures the exact amount of medication prescribed.

An initial assessment is performed on a client in the clinic. What is the primary purpose of this assessment?

1. To see if the medication from the last visit worked.
2. To establish a baseline for future comparisons.
3. To perform the implementation phase.
4. To decide on the final nursing diagnosis.

Correct Answer: 2

Rationale: An initial assessment provides a thorough evaluation and baseline data against which future (ongoing) assessments are compared.

The nurse is preparing a teaching plan for a client with a new diagnosis of diabetes. Which phase of the nursing process is this?

1. Assessment
2. Planning
3. Implementation
4. Evaluation

Correct Answer: 2

Rationale: The planning phase involves selecting interventions and developing teaching plans based on expected outcomes.

Which action by the nurse occurs during the Implementation phase?

1. Formulating a nursing diagnosis.
2. Setting a goal for blood pressure to be 120/80\text{ mmHg}.
3. Administering an oral antibiotic to the client.
4. Asking the client if the antibiotic caused any nausea.

Correct Answer: 3

Rationale: Implementation is the actual 'carrying out' of the plan, such as the physical administration of drugs.

A client is scheduled for a medication at 0900. The nurse administers it at 0905. Which of the six rights did the nurse adhere to?

1. Right Drug
2. Right Time
3. Right Route
4. Right Dose

Correct Answer: 2

Rationale: 'Right Time' involves administering the medication within the facility's approved timeframe relative to the ordered time.

A nurse identifies that a client is interested in improving their current health status. Which NANDA-1 diagnosis fits this scenario?

1. Deficient Knowledge
2. Ineffective Health Management
3. Health Seeking Behavior
4. Anxiety

Correct Answer: 3

Rationale: Health Seeking Behavior is a nursing diagnosis used when a client is motivated to achieve a higher level of wellness.

The nurse checks the client's wristband and asks for their name and date of birth. Which right is being satisfied?

1. Right Patient
2. Right Drug
3. Right Documentation
4. Right Time

Correct Answer: 1

Rationale: Using two identifiers (name and DOB) ensures the medication is given to the 'Right Patient'.

A client complains of itching after the first dose of a new drug. The nurse notes hives on the client's chest. This is an example of what?

1. An expected outcome
2. A nursing diagnosis
3. An adverse drug reaction
4. Subjective data only

Correct Answer: 3

Rationale: Adverse reactions are monitored during ongoing assessment and evaluated to determine if the drug therapy should continue.

A nurse is determining if the client can self-administer eye drops. Which phase of the nursing process is the nurse currently in?

1. Evaluation
2. Assessment
3. Planning
4. Implementation

Correct Answer: 2

Rationale: Assessment involves collecting data (in this case, the client’s physical ability to use eye drops) before planning or carrying out the task.

What is the primary reason nurses use the NANDA-1 taxonomy?

1. To prescribe medications to clients.
2. To standardize nursing diagnosis terminology.
3. To replace the physician's medical diagnosis.
4. To create billing codes for insurance.

Correct Answer: 2

Rationale: NANDA-1 was formed to standardize the language and terminology nurses use to identify client problems.

A nurse chooses the intervention 'Provide written instructions for medication' for a client. This occurs in which phase?

1. Assessment
2. Planning
3. Implementation
4. Diagnosis

Correct Answer: 2

Rationale: Selection of specific interventions to meet outcomes occurs during the planning phase.

The nurse notes the client's skin is cool and clammy. This is an example of:

1. Subjective data
2. Objective data
3. An intervention
4. An outcome

Correct Answer: 2

Rationale: Physical findings such as skin temperature and moisture are objective facts gathered through physical assessment.

Before giving a drug, the nurse reviews the client's allergy history. This is part of which step?

1. Evaluation
2. Implementation
3. Assessment
4. Planning

Correct Answer: 3

Rationale: Collecting a health history, including allergies, is part of the initial and ongoing assessment process.

An outcome states: 'The client's baseline blood pressure will be maintained.' This is an example of a goals for:

1. Implementation
2. Nursing Care
3. Diagnostic reasoning
4. Subjective reporting

Correct Answer: 2

Rationale: Goal statements indicate the broad expectations for the client's progress in nursing care.

A nurse determines that a client is not taking their medication because they cannot read the fine print on the bottle. This clinical judgment is part of:

1. Assessment
2. Nursing Diagnosis
3. Implementation
4. Evaluation

Correct Answer: 2

Rationale: Nursing diagnosis uses clinical judgment to identify the cause of the problem (e.g., Ineffective Health Management due to sensory deficit).

A nurse reads an order that says 'Give 5.0\text{ mg} IV.' The nurse realizes the route is IV (intravenous). This is one of the:

1. Five phases of nursing
2. Six rights of drug administration
3. NANDA-1 categories
4. SMART criteria

Correct Answer: 2

Rationale: The 'Right Route' is a core component of the six rights of drug administration.

The nurse assists the client in practicing deep breathing exercises for anxiety. This is which phase?

1. Assessment
2. Planning
3. Implementation
4. Evaluation

Correct Answer: 3

Rationale: Carrying out the nursing actions or interventions is the implementation phase.

Which statement by the client indicates that the 'Evaluation' of their teaching was successful?

1. "I don't think I need to take these pills."
2. "I will take this medication with food as you instructed."
3. "Can you explain the medicine again?"
4. "I'm feeling very anxious about this."

Correct Answer: 2

Rationale: Evaluation is successful if the client demonstrates understanding of the drug regimen or if progress toward the outcome is made.

The nurse conducts an assessment at every shift change. This is called:

1. Initial assessment
2. Nursing diagnosis
3. Ongoing assessment
4. Goal setting

Correct Answer: 3

Rationale: Ongoing assessment occurs at each encounter to compare against the baseline data and monitor for changes.

A nurse decides to change a client's position to help with breathing after medication. This action is part of:

1. Assessment
2. Planning
3. Implementation
4. Diagnosis

Correct Answer: 3

Rationale: Repositioning the client is a nursing action performed during the implementation phase to support therapy.

Define: The Nursing Process

A systematic framework for nurses to problem-solve and provide effective, individualized client care.

Step 1: Assessment

The collection of objective and subjective data to establish a baseline for client care.

Step 2: Nursing Diagnosis

The use of clinical judgment to identify client health problems that can be solved or prevented by nursing actions.

Step 3: Planning

The phase where the nurse sets SMART goals/expected outcomes and selects appropriate nursing interventions.

Step 4: Implementation

The action phase where the nurse carries out the plan, including the administration of drugs and client teaching.

Step 5: Evaluation

The final phase where the nurse measures the effectiveness of interventions and checks if expected outcomes were met.

Definition: Objective Data

Measurable, observable facts obtained through physical assessment, such as vital signs and lab results.

Definition: Subjective Data

Information provided by the client or their family regarding feelings, symptoms, or personal reports.

Definition: Initial Assessment

A thorough evaluation conducted when a client is first admitted or seen to establish baseline data.

Definition: Ongoing Assessment

Evaluations conducted at every client encounter to monitor for changes, drug effectiveness, or adverse reactions.

Define: NANDA-1

The North American Nursing Diagnosis Association-International, which standardizes the terminology used for nursing diagnoses.

Define: SMART Criteria

Guidelines for writing expected outcomes: Specific, Measurable, Achievable, Relevant, and Time-bound.

List: The Six Rights of Drug Administration

1. Right Patient
2. Right Drug
3. Right Dose
4. Right Route
5. Right Time
6. Right Documentation

Definition: Goal Statement

A broad expectation in the planning phase indicating that a client's problem has been solved.

Definition: Expected Outcome

A specific, measurable change in a client's status that is expected to result from nursing care.