Question 15
Type: MCSA
The nurse wants to create an intervention to assist a client with ambulation. Which statement is the most
appropriate manner for the nurse to write this intervention?
1. Assist client with ambulation.
2. Ambulate with client, using a gait belt, twice daily for 15 minutes.
3. Make sure client understands the rationale for using the gait belt.
4. Client will ambulate in hallway twice daily.
Question 16
Type: MCSA
A hospital is implementing the use of the NIC (Nursing Interventions Classification) taxonomy. What purpose
will the implementation of this taxonomy serve?
1. Help the nurse with documentation of the care plan
2. Require that the nurse use sound judgment and knowledge of the client
3. Match nursing diagnoses to exact interventions
4. Help the nurse choose activities that are individualized to the client
Question 17
Type: MCSA
The nurse identifies the diagnosis Risk for aspiration, related to neuromuscular dysfunction for a client who
experienced a cerebrovascular accident. Which intervention should the nurse identify as including a rationale?
1. Have suction equipment available at all times.
2. Clear secretions from oral/nasal passageways as needed.
3. Keep client in low-Fowler’s position to prevent reflux.
4. Provide frequent assessment for presence of obstructive material in mouth and throat.
Question 18
Type: MCMA
The nurse manager is implementing computerized care plans for the care area. Which guidelines should the
manager emphasize when the staff is writing care plans?
Standard Text: Select all that apply.
1. Plans must be dated and signed.
2. Categories must have headings.
3. Plans must be specific.
4. Plans must include preventive care and health maintenance.
5. Plans must include interventions for ongoing assessment.
6. Plans are standardized and generalized for all clients.
Question 19
Type: MCMA
The nursing staff is reviewing standards of care, standardized care plans, protocols, policies, and procedures for a
multi-system health care facility. Why are these documents important to the nursing staff when providing client
care?
Standard Text: Select all that apply.
1. To make sure all clients have the same type of care
2. To ensure that minimally accepted standards of care are met
3. To promote efficient use of the nurse’s time
4. To eliminate care disparities among clients
5. To minimize health care costs
Question 20
Type: MCMA
The nurse is devising a care plan for a client with complex health issues and current acute health problems. Which
criteria should the nurse ensure is used when planning interventions for this client?
Standard Text: Select all that apply.
1. Congruent with the client’s values, beliefs, and culture
2. Are within established standards of care
3. Based on scientific and medical knowledge
4. Achievable with the resources available
5. Must be safe and appropriate for the client’s age
Question 21
Type: MCMA
The nurse is reviewing a client’s plan of care. Which statements indicate that this care plan has been completed
accurately and appropriately?
Standard Text: Select all that apply.
1. Ineffective coping related to drug abuse as evidenced by drug overdose.
2. The client will identify two healthy coping mechanisms by time of discharge.
3. The client has identified two health coping mechanisms to replace inappropriate drug use.
4. The client will be provided with guidance in identifying healthy coping mechanisms.
5. The client has apologized to his family for drug abuse behaviors.
Question 22
Type: MCMA
The nurse attends an educational program that provides information about the Nursing Intervention
Classifications (NIC) system. Which statements made by the nurse indicate that teaching has been effective?
Standard Text: Select all that apply.
1. “I can look up interventions according to the nursing diagnosis that I’ve selected.”
2. “The interventions connected to a diagnosis are appropriate for any client with that diagnosis.”
3. “If there is a NANDA diagnosis, I should be able to find some appropriate interventions.”
4. “Care plans are best written when the interventions are broad and flexible.”
5. “I find NIC interventions a really good place to start when I’m working on client interventions.”
New Questions:
Question 23
Type: MCMA
The nurse is collecting information to plan care for a client with a heart problem. Which information indicates that
planning for this client’s discharge was started by the nurse?
Standard Text: Select all that apply.
1. The client is scheduled for cardiac catheterization and echocardiogram.
2. Recent laboratory data indicates the development of heart failure.
3. The client does not have a scale to perform daily weights at home.
4. The client’s spouse has care needs that the client will not be able to complete going forward.
5. The client is pleasant and eager to learn how to control newly diagnosed health problem.
Question 24
Type: MCMA
The nurse is creating goals for a client’s plan of care. For what reasons should the nurse expect to use these goals?
Standard Text: Select all that apply.
1. Serve as criteria to evaluate the client’s progress
2. Determine when the problem has been resolved
3. Motivate the client to provide a sense of achievement
4. Use as a measuring stick to limit the use of hospital resources
5. Provide direction when planning the client’s nursing interventions
