Ch 18-20

Which patient problem would be a high priority?

Chest pain

Which activity would the nurse perform when implementing indirect care measures?

Collecting and transporting labeled specimens

Which action would the nurse take for a patient who has an outcome of walking the entire hallway by 10/17 and the patient walks halfway down the hallway on 10/16?

Continue with the care plan

Which action performed for the patient is a nurse-initiated intervention?

Elevating an edematous leg Offering counseling for coping Initiating early mobility protocols

Which action would the nurse perform when modifying a care plan after a patient has been evaluated?

Evaluate the interventions Redefine nursing diagnoses Reassess patient factors

Which element is the final step of the nursing process?

Evaluation

Which capability of the nurse would help in choosing suitable nursing interventions?

Functioning within a particular setting of the health care unit Knowing the scientific rationale for the intervention Possessing the necessary psychomotor and interpersonal skills

Which action would be classified as a health care provider-initiated intervention?

Giving medication Starting an intravenous (IV) solution Preparing a patient for an x-ray

Which question would the nurse ask to evaluate a patient's expectations of care?

Have you received adequate pain relief care?"

Which initial action would the nurse take when the goals are not being met as a result of the patient's response to illness?

Reassess the patient

Which action would the nurse take when a nursing goal is not met in the care of a patient?

Reassess the patient Repeat the entire nursing process Revise the care plan

When delivering patient care, which intervention does the nurse perform as part of the evaluation process?

Recognizes unmet outcomes

Which problem is considered a high priority for a patient?

Reduced oxygenation Insufficient circulation

Prioritize the nursing diagnoses for an older-adult patient with pneumonia who is fatigued and lives alone.

Reduced oxygenation Threat of immobility Poor health management Possible isolation from the community

Which patient indicator would be used to measure a reduction in pain level for a patient?

Reports pain severity Identifies the frequency of pain Uses a pain scale to rate pain

Which action is an example of a dependent nursing intervention?

Inserting a Foley catheter Dressing a surgical incision wound Administering an antidepressive drug

Which option would be an appropriate goal statement for a patient at risk of an infection?

Patient's wound will remain free of infection by discharge

Which prevention level would describe a clinic nurse screening a patient for diabetes?

Secondary

Which level of prevention describes a nurse conducting health awareness training programs at a community center?

Primary

Which action is an example of an independent nursing intervention?

Provide health education Assist with daily activities Reposition a patient

For which patient would a short-term goal be most appropriate?

A patient who experiences acute pain related to incisional trauma

Which action would the nurse take when administering a new, unfamiliar medication to a patient who cannot have food or fluids for 24 hours?

Ask the pharmacist for help Consult an experienced nurse for help regarding the drug Look up the medication in a drug book

Which action would a student nurse take when asked to perform a procedure that the student nurse has been trained in but has not performed in the hospital?

Check the hospital's procedure manual to obtain more information Ask an experienced nurse for supervision and guidance during the procedure Verbalize the steps of the procedure with an instructor before performing it

Which action is classified as an indirect care measure

Checks the monthly performance improvement report on fall occurrences on a unit Consults with a dietitian about a patient's therapeutic diet food choices

Which type of nursing intervention is an interdependent intervention?

Collaborative

Which criterion is an evaluative measure to determine healing of a chronic, nonhealing skin ulcer in an elderly patient who has diabetes and is receiving antibiotics?

Color of the ulcer Diameter of the ulcer Odor in the ulcer

Which action would be an example of a collaborative intervention?

Consult with dietitian on initial foods to offer patient

The health care provider prescribes interventions to the nurse to treat the medical diagnosis of the patient. To which category does such an intervention belong?

Dependent

Which type of action would describe a nurse performing cardiopulmonary resuscitation (CPR) for a patient in cardiac arrest?

Direct care Lifesaving measure

Which action would be appropriate when the clinic nurse teaches interventions to a patient who is diagnosed with a urinary tract infection and during the follow-up visit, the patient's laboratory report shows an absence of infection?

Discontinue the care plan

Which option is an example of a nurse managing indirect care activities?

Infection control

Which nurse-initiated intervention would the nurse perform to help an anxious male patient express acceptance of his health status?

Listen attentively to the patient Use a calm and reassuring approach Provide factual information regarding recovery

Which nursing intervention is correctly written and the nurse would add to the plan of care?

Measure blood glucose before each meal: 7:00 AM, 11:00 AM, and 5:00 PM Turn the patient every 2 hours from supine to prone to right side

Which feature is typical of an intermediate priority nursing diagnosis?

Nonemergent

Which expected outcome would be appropriate for a patient who is vomiting?

Patient stops vomiting in 2 hours

Which type of implementation skill is described when the nurse correctly administers an enema solution to a patient?

Psychomotor

Which characteristic of nursing goals and expected outcomes would the nurse keep in mind when developing a care plan?

Realistic Attainable Specific to patient

Which activity is classified as an instrumental activity of daily living (IADL)?

Shopping House cleaning Preparing meals

Which statement is true about discharge planning?

Start discharge planning at admission Involve family members in discharge planning

Which interpretation would the nurse make regarding a patient with pneumonia whose cough decreased and respiratory rate decreased from 33 to 25 breaths/min after nebulization treatments?

The patient needs continued nebulization therapy

Which outcome is correctly written and would the nurse add to the plan of care about the patient's apical pulse?

The patient's apical pulse will be at least 70 beats per minute

Place the following events in order of priority, starting with the most important event

The patient's vital signs change, showing a drop in blood pressure The patient expresses concern about pain The family comes to visit the patient The charge nurse approaches the nurse and requests a report at end of shift

Which word does the letter "T" represent in the SMART acronym as it relates to setting goals for the patient?

Timed

Setting a time frame for outcomes of care determines which purpose?

When the patient is expected to respond in the desired manner

Which factor would the nurse consider when making discharge plans for activities of daily living (ADLs)? Select

paralyzed patient will need permanent assistance for ADLs Patients should be encouraged to participate in ADLs Family members can be allowed to assist the patient, as needed

Which nursing intervention is an example of direct care for a patient?

Administering medications Inserting an intravenous (IV) line Counseling the patient about required care

When does implementation begin?

After the care plan has been developed

Which problem would the nurse add to the care plan after evaluating a diabetic patient who had a problem with glucose control but is now restless and asking many questions about an upcoming procedure on the big toe?

Anxiety

Which option correctly describes a nurse's actions?

Calling an ostomy and wound care specialist is an indirect care measure. Cleansing the skin is a direct care measure Applying a skin barrier is a direct care measure

Which action would the nurse take for a patient who continues to have congested lungs after coughing and deep-breathing exercises?

Increase frequency of coughing and deep-breathing exercises

Which category is a type of nursing intervention?

Interdependent Nurse-initiated Health care provider-initiated

Which implementation skill describes a nurse explaining to the patient about inserting a feeding tube?

Interpersonal

Which component would be included in a comprehensive nursing care plan?

Nursing diagnoses Expected outcomes Evaluation findings

Which outcome would be appropriate for the depressed patient who lost weight but has a goal to return to baseline weight in 3 months?

Patient achieves an intake of 2400 calories daily in 2 weeks Patient reports improvement in appetite in 1 week

Which statement describes the unique difference between a hospital's nursing care plan and the home care plan?

The patient and family need to be able to provide most of the health care

Which expected outcome is correctly written and would be appropriate for a patient who must have surgery for a knee injury?

The patient describes the purpose of surgery after talking to the surgeon The patient discusses the surgical outcomes with the surgeon in 24 hours. The patient describes activity restrictions to follow by discharge in 48 hours

Which conclusion would the nurse infer when during a follow-up visit, the patient's wound infection is resolved and the patient followed proper instructions?

The patient has met the expected outcome

Which intervention would the nurse add to the nursing care plan to reduce anxiety in a patient?

Use a reassuring approach in discussions Teach the patient relaxation exercises using deep breathing Work with the health care provider to provide factual medical information

Which patient finding would be the most suitable nursing-sensitive outcome for a patient who is immobile, does not ambulate, and has a nursing diagnosis of backache?

Will have reduced back pain

Which initial action would the nurse take for a postoperative patient who realizes that strain on the incision site could cause tearing of the stitches, but some of the patient's stitches are pulled out?

Ask if the patient understands which activities can cause strain at the incision site

A patient had high blood sugar when the nurse tested it previously, but the patient says the blood sugar was normal when tested at home right before coming to the clinic. Which action would the nurse take next?

Ask the patient to show the technique for checking blood sugar levels

Which implementation skill describes the nurse considering facts about nausea, the anatomy of the gastrointestinal tract, and the physical mechanisms for nausea and vomiting?

Cognitive

Which type of action would describe a nurse performing cardiopulmonary resuscitation (CPR) for a patient in cardiac arrest?

Direct care Life saving measure

Which action would the nurse take for a patient who agrees with the nurse that expected outcomes were met?

Discontinue the care plan.

A patient with a fractured ankle has an expected outcome of walking with crutches. The patient is able to walk with crutches after instruction from the nurse. Which action would the nurse take next for this patient?

Discontinue the current interventions

Which characteristic is a component of well-written goals and expected outcomes?

Observable Timed Patient-specific

Which action describes an independent nursing intervention?

Offering counseling for coping Initiating early mobility protocols Instructing patients on side effects of medications Positioning patients to prevent pressure injury formation

Which type of problem is a high priority?

One related to life-threatening needs of the patients

Which principle of care coordination would the nurse use to achieve a desired outcome for patients?

Organizational skills Good time management Appropriate use of resources

Which evaluative measure would the nurse use to determine care for a patient with a myocardial infarction (heart attack)?

Patient rates the pain level

Which expected outcome for the goal "Patient will achieve a gain of 10 pounds (4.5 kg) in body weight in a month" is written correctly?

Patient will eat at least three-fourths of each meal by the end of 1 week

Which outcome would be directly related to the goal of pain relief for a confused patient?

Patient will express three or fewer nonverbal signs of discomfort

Which expected outcome is written in measurable terms?

Patient will report pain acuity less than 4 on a scale of 0 to 10.

The nurse would evaluate which goal based upon the following reassessment: upon removal of the intravenous (IV) line from the right arm, the site was clean and dry with no signs of redness or tenderness?

Patient's IV site will remain free of infection

Which factor would the nurse consider before setting a goal that the patient will self-administer insulin injections?

Patient's ability to meet the goal Patient's cognitive function Availability of the patient's support network to assist

Which goal is appropriate for the patient who is at high risk of skin injuries?

Patient's skin will remain intact through discharge

Which action would the home-health nurse take first when during a follow-up visit, the nurse finds the goal not met?

Perform a reassessment

Place the steps of consultation in the correct sequence

Place the steps of consultation in the correct sequence Direct the consultation to the right professional Provide the consultant with relevant information about the problem area Be available to discuss the consultant's findings and recommendations. Incorporate the consultant's recommendations into the care plan

Which action would the nurse take when arranging supplies and equipment before administering an intravenous (IV) antibiotic to a patient?

Place the supplies in a convenient location Check whether the equipment is working properly Decide what supplies will be needed for the procedure

Which intervention would be appropriate for a postoperative patient who is on bed rest and at risk of skin injuries after surgery?

Reposition the patient frequently Administer analgesics before turning Use pressure relief devices, if necessary

Which resource would the nurse use to develop a plan of care?

Scientific literature Standard protocols Procedure manuals Nursing Interventions Classification

Which intervention indicates the nurse is delivering ethical care?

Understanding the patient's expectations

Which option would be a suitable nursing-sensitive expected outcome for a patient with acute pain?

Reports pain severity reduced from 8 to 6 in 2 days

Which nursing-sensitive patient outcome is a component of quality health care?

Incidence of pressure injuries Number of patient falls

Which tip would be helpful when a nurse is making a phone consultation?

Assess the patient thoroughly before making the call Have the complete information about the problem before the call Understand the reason behind the call and think through some possible solutions Use the Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) approach in reporting details of the case

Which element is a chief component of the nursing process?

Assessment Diagnosis Implementation

Which action would the nurse take when the patient asks for a bedpan as the nurse is reassessing the patient?

Assist the patient onto the bedpan

Which action would the nurse take during consultations?

Avoid bias by not sharing subjective and emotional conclusions

Which intervention performed by the nurse is an interdependent intervention?

Consulting with a physiotherapist for postoperative exercises Collaborating with the home health department to ensure the patient will have home health visits Conferring with the unit discharge coordinator to help the patient return home

Which category is a level of the Nursing Interventions Classification (NIC) model?

Domains Classes Interventions

Which step of the nursing process describes the nurse observing that the patient's redness on the heels has decreased over the past 2 days after using measures to relieve pressure points?

Evaluation

Which step of the nursing process is the nurse performing when he or she asks the patient to rate pain 45 minutes after administering an analgesic?

Evaluation

Which criterion is used to evaluate efficacy of interventions?

Expected outcome

Which response would the nurse make for a patient who expresses confusion about how to manage a leg wound after discharge?

Explain and demonstrate the necessary action to the patient

Which intervention performed by the nurse would require an order from a health care provider?

Getting an x-ray of the chest to rule out pulmonary complications Administering an antibiotic to prevent infection Starting an intravenous (IV) infusion of normal saline

Which standard would the nurse use to evaluate a middle-aged patient's response to chemotherapy?

Goals Outcomes

Which priority level would be assigned to the patient diagnosed with decreased gas exchange?

High

Which action would the nurse take while documenting and reporting the evaluation of care for a patient?

If a patient is not progressing, the nurse would report it to the health care team members

Which determination does an evaluative measure make?

If nursing care was effective for meeting expected outcomes

Which information correctly describes the evaluation process?

Is a complex process Involves making clinical decisions Requires the use of assessment skills

Which statement is true about the standards of care?

It is the minimum acceptable level of care to ensure that a patient receives high-quality care

Which action would the nurse perform when managing supplies required for a patient's minor procedure?

Keep some extra supplies handy

Which activity would the nurse include in a nursing plan for indirect care of a patient?

Manage the patient's environment

Which activity would be a component of the evaluation phase of the nursing process?

Measuring a patient's clinical progress Judging if the desired change has occurred

Which information would the nurse share with the patient when starting an intravenous (IV) medication?

Name of the medication that is given through the IV line Duration of time that the IV bag will last Physical sensations that the medication may cause Expected sensation if the IV site becomes inflamed

Which method would the nurse use when teaching a patient about foot care?

Repeat instructions as needed, having the patient do a return demonstration

Which intervention is correctly written and would be added to the plan of care for a patient with a wound and risk of skin breakdown?

Provide perineal care, using mild soap and water, every shift and after each episode of urinary incontinence Apply transparent dressing to wound according to protocol (every 4 days) Irrigate wound with 100 mL normal saline until clear: 6:00 AM, 2:00 PM, 8:00 PM

Which action would the nurse perform first when he or she enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned?

Reconnect the drainage tubing

Which action would the nurse take when the patient who is nothing by mouth (NPO) (no food or fluids allowed) develops an adverse reaction to a new intravenous (IV) drug?

Record the reaction Stop further administration of the drug Notify the health care provider

Which action would be implemented when the nurse is unsure about implementing fall prevention guidelines for an older-adult patient?

Refer to the clinical practice protocol

Which action demonstrates nursing competency when evaluating a patient?

Reflect on the situation Understand a patient situation Recognize errors or omissions Examine the results of care according to clinical data collected Compare achieved effects with goals and expected outcomes

Which action by the nurse reflects critical thinking while implementing interventions with patients?

Review all potential complications associated with the interventions

In which order would the nurse modify the patient's plan of care?

Revise the assessment data Add a new nursing diagnosis Select new goals and outcomes Select interventions according to the new diagnosis Determine evaluation criteria

Which action would the nurse perform when revising a nursing care plan?

Revise the nursing diagnoses Add new data with appropriate dates Choose the method of evaluation for monitoring patient outcomes

Which action would the nurse perform to redefine the diagnosis after evaluation of a patient goal?

Revise the patient's problem list

Which step would the nurse follow when performing an unfamiliar procedure?

Seeks necessary knowledge Reassesses the patient's condition Collects all necessary equipment Considers possible consequences of the procedure

Which factor helps ensure quality data collection of nursing practices and enables evaluation across health care organizations?

Standard nursing language

Which type of order describes a prewritten prescription in the intensive care unit (ICU) that states in case of a headache, acetaminophen is to be given to the patient?

Standing order

Which information accurately describes a physical care technique?

Staying organized while caring for the patient Protecting oneself and the patient from injury Using proper hygienic infection control practices

Which modification would the nurse make to the care plan for a patient with diabetes who can no longer prepare or administer insulin because of tremors and has a caregiver who lives in the home?

Teach the caregiver to prepare and inject the insulin

Which intervention performed by the nurse is an independent nursing intervention?

Teaching the patient about deep-breathing exercises Assisting the patient in taking a bed bath Repositioning a patient for relief from pain

Which level of prevention describes the nurse working in collaboration with a physiotherapist to help aid the ambulatory functions of a patient who suffered a motor vehicle accident?

Tertiary

Which patient response would indicate that the expected outcome of describing signs and symptoms of a wound infection has been met?

There will be more tenderness around the incision if I have an infection.

Which statement or action by the nurse is characteristic of an effective hand-off report?

This patient is anxious about pain after surgery; you will need to review the information about how to use a patient-controlled analgesia (PCA) pump this evening.

Which action indicates that the nurse is using physical care techniques?

Using safe patient-handling procedures