Fundamental EAQ

The nurse is assigned to care for a patient with a medical disorder. After data collection, how does the nurse identify the patient problem? Listing all data collected Excluding problem areas Using web-based information Analyzing the assessment data

Analyze assessment data

A patient has returned from surgery with a health care provider's order for the use of incentive spirometry (IS) every 2 hours. The nurse teaches the patient about the importance of breathing deeply to clear any secretions and to prevent pneumonia. Which phrase is this teaching an example of?

Implementation of a nursing intervention

A patient has returned from surgery with a health care provider's order for the use of incentive spirometry (IS) every 2 hours. The nurse teaches the patient about the importance of breathing deeply to clear any secretions and to prevent pneumonia. Which phrase is this teaching an example of? 1 The delivery of a patient problem 2 Explanation of an outcome statement 3 A correct example of the nursing process 4 Implementation of a nursing intervention

Implementation of a nursing intervention

Considering Maslow's hierarchy of needs, which patient problem would be of the highest priority? 1 Lack of education about diagnosis 2 Inability to tolerate food and drink 3 Pain not being alleviated by pain medication 4 Risk of skin integrity being compromised by immobility

Inability to tolerate food and drink

After the gathering of subjective and objective data, obtaining a health history, and performing a physical assessment, the nurse is ready to set up a plan of care. Which step is first?

Patient problem statement statement is the title or label given to an identified problem and is the first step in a patient's plan of care. A medical diagnosis is the problem identified by the primary health care provider upon the patient's admission. Nursing intervention is the action used to meet the goal of the plan of care. Evaluation is the last step in the plan of care to see if the interventions are working or need to be changed.

After the gathering of subjective and objective data, obtaining a health history, and performing a physical assessment, the nurse is ready to set up a plan of care. Which step is first? 1 Evaluation 2 Medical diagnosis 3 Patient problem statement 4 Nursing intervention

Patient problem statement The patient problem statement is the title or label given to an identified problem and is the first step in a patient's plan of care.

A nurse is working in a busy medical-surgical unit. Among the various tasks the nurse has planned, which task needs to be performed first? Administering an insulin injection to a patient with diabetes waiting for food Changing the wound dressing of a young patient Measuring the vital signs of a stabilized postoperative patient Administering antipyretic medication to a patient with moderate fever

Administering an insulin injection to a patient with diabetes waiting for food

After implementing an intervention identified on the patient's plan of care, which step would the nurse take next? 1 Formulate a diagnosis. 2 Set a specific expected outcome. 3 Evaluate the patient's response. 4 Document the patient's response.

3. Evaluate patient response

While providing care, the nurse omits washing or sanitizing hands between patients to save time. Which statement best describes the nurse's behavior? 1 It is acceptable as long as proper care is given. 2 It is within the guidelines of professional standards. 3 This action puts patients at risk for health care-associated infections. 4 Because of this timesaving technique, patients receive high-quality care

this action puts patients at risk for health care associated infections

Which precaution does the nurse take to minimize the risk of spreading infection after attending to a patient? 1 Use ice cold water for hand washing. Incorrect2 Use water on full force for hand washing. 3 Lean against the sink during hand washing. 4 Use lukewarm running water for hand washing.

use lukewarm running water

Which measure is appropriate for the nurse to take to prevent the spread of infection while caring for a patient with an infection? 1 Use hand sanitizer. 2 Use proper hand hygiene. 3 Give antibiotics to the patient. 4 Keep the patient's wound open

use proper hand hygiene

A nurse has just completed the interview and the physical assessment of a patient. Which action would the nurse take next? 1 Planning the needed care 2 Reassessing the patient 3 Formulating a patient problem statement 4 Evaluating patient outcome

3) Formulating a patient problem statement Once the data have been collected via the interview and the physical assessment, the nurse clusters the data to formulate a patient problem statement or statements. There is no need to reassess because this is done after the patient has been evaluated to determine whether goals were met. The outcomes are evaluated once implementation has taken place.

Which component of the nursing process includes the degree of wellness desired, expected, or possible for the patient to achieve and contains a patient goal statement? 1) Planning 2)Assessment 3)Implementation 4) Outcomes identification

4) outcome identification The outcome statement indicates the degree of wellness desired, expected, or possible for the patient to achieve and contains a patient goal statement. Planning includes the licensed practical/vocational nurse (LPN/LVN) and the registered nurse (RN), and both plan interventions that will help meet the patient's desired goals.

When a nurse reflects on care that was given and determines what was effective, in addition to analyzing and adjusting given care, which process is involved?

Critical thinking

When a nurse reflects on care that was given and determines what was effective, in addition to analyzing and adjusting given care, which process is involved? Critical thinking 2 The nursing notes 3 The patient problem statement 4 The nursing care plan

Criticial thinking

Which nurse-prescribed intervention is an appropriate intervention for a patient with a deep vein thrombosis (DVT) in the right leg? Assessing level of pain with each assessment of the right leg perfusion Assessing vital signs if capillary refill is decreased from previous assessment Ensuring complete bed rest with right leg elevated on two pillows at all times Monitoring laboratory values every 4 hours and report abnormalities to primary care provider

Ensuring complete bed rest with right leg elevated on two pillows at all times

Which phrase best describes the outcomes identification phase of the nursing process? The information received from the patient during a physical assessment A set of expected obligations the patient is required to meet at discharge Expected outcomes for diagnoses developed by the patient and the nurse Required criteria that a primary health care provider develops for a nurse to achieve before shift change

Expected outcomes for diagnoses developed by the patient and the nurse

Which infection requires airborne precautions in addition to standard precautions? 1 Mumps 2 Measles 3 Respiratory syncytial virus 4 Enteric infection with Escherichia coli

Measles If a patient has measles, airborne precautions would also be used to prevent infection transmission. Mumps require droplet precautions in addition to standard precautions, not airborne. Contact precautions in addition to standard precautions would be used for a patient with an enteric infection with Escherichia coli as well as for a patient with respiratory syncytial virus.

Daily nursing activities, such as hand hygiene and linen changes, are considered which type of asepsis? 1 Antiseptic use 2 Disinfection 3 Surgical asepsis 4 Medical asepsis

Medical asepsis Medical asepsis consists of techniques that inhibit the growth and transmission of pathogenic microorganisms and is used during hand hygiene and linen changes. Use of an antiseptic agent inhibits the growth and reproduction of microorganisms. Disinfection involves application of a chemical to objects to destroy microorganisms. Surgical asepsis, which consists of a technique designed to destroy all microorganisms and spores, is used for surgery or invasive procedures.

Which mask does the nurse use while in contact with a patient who has infection with Mycobacterium tuberculosis? 1 N95 respirator mask 2 N100 face mask 3 N85 surgical mask 4 N90 dust/fume/mist (DFM) mask

N95 respirator mask

A student nurse looking through a chart sees the following: "By the third admission day, the patient will demonstrate the technique for self-administering subcutaneous injections." This information would be listed under which phase of the nursing process? 1 Evaluation 2 Assessment 3 Implementation 4 Outcomes identification

Outcomes identification The outcome statement indicates the degree of wellness desired. The outcome statement guides the selection of the nursing interventions, and it measures the standards used to evaluate the effectiveness of the interventions

Priorization occurs at what stage?

Planning

A patient complains of breathlessness. Which nursing action is a part of the implementation phase of the nursing process? Assess the respiratory rate. Plan to provide oxygen therapy. Prop up the patient in Fowler's position. Assess whether the patient is feeling better.

Prop Patient in fowlers position

Which type of data source would the nurse consider if a patient's family tells the nurse that the patient has seemed very depressed lately?

Secondary Secondary sources of data include family members and significant others. The patient is a primary source of data. Subjective and objective are types of data not sources of data.

Steps of planning and providing care to a patient.

The first step in caring for a patient is data collection, which involves collecting all possible information pertaining to the patient's health status. After data collection, the nurse has to set up a plan of action for caring for the patient based on the patient problem identified through the patient data. The next step is to implement the plan of action; last, the nurse evaluates the patient for attaining desired outcomes. Test-Taking Tip: In this Question Type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing a nursing action or skill, such as those involved in medication administration.

Which laboratory value would the nurse assess if concerned about infection in a patient? 1 Hematocrit (Hct) 2 Hemoglobin (Hgb) 3 Red blood cells (RBCs) 4 White blood cells (WBCs)

White Blood cells The WBC count is the laboratory value that indicates the possibility of an infection. The RBC count does not indicate infection. The Hgb (Hemoglobin) value does not indicate infection. The Hct (Hematocrit) value does not indicate infection. All three of these laboratory values address quantity and quality of RBCs.

Which stage of the infectious process is exhibited by a patient with symptoms of a cold, including congestion, coughing, and fever? 1 Acute 2 Prodromal 3 Incubation 4 Convalescence

acute stage of the infectious process: the patient manifests signs and symptoms specific to the type of infection. During the prodromal stage, the patient begins with nonspecific signs and symptoms, progressing toward specific signs and symptoms (the acute stage). In the incubation stage, there are generally no signs and symptoms. In the convalescence stage, acute symptoms of the infection disappear.Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

If changes need to be made to the plan of care, during which phase would one expect this to occur? Diagnosis Evaluation Assessment Outcomes identification

evaluation The evaluation phase is a determination made about the extent to which the established outcomes have been achieved. The plan of care generally undergoes any changes during this phase of the nursing process. Expected outcomes for established diagnoses are developed by the patient and the nurse. The outcome statement indicates the degree of wellness desired, expected, or possible for the patient to achieve and contains a patient goal statement.