Kozier & Erb’s 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 client’s care?
1. The admitting nurse
2. All nurses who work with the client
3. Everybody involved in this client’s care
4. The client and the client’s support system
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
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 client’s care?
1. Informal nursing care plan
2. Formal nursing care plan
3. Standardized care plan
4. Individualized care plan
Question 4
Type: MCMA
The nurse being oriented to a new position is reviewing the hospital’s 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 nurse’s time
4. Eliminating care disparities among clients
5. Ensuring medication errors do not occur
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
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
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 client’s home.
2. Assist the client in finding an alternative plan for the achieving the therapy’s 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.
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.
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.
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
Page Number: 197
Question 11
Type: MCSA
The nurse is caring for a client with Parkinson’s 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.
Question 12
Type: MCSA
The nurse is reviewing interventions written for a client’s 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
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
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.