pharma4-5 Q-A

Arrange the components of the nursing process in the proper order. Planning Assessment Implementation Evaluation Diagnosis

1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

A patient develops edema as an adverse effect to a prescribed medication. A gain of 5 pounds has occurred in 24 hours, and 2+ edema is present in the legs. Which nursing diagnosis statement does the nurse allocate to this patient? I 1. Excess fluid volume related to calcium ion antagonist therapy (nifedipine), as evidenced by dependent edema (2+) and weight gain of 5 pounds in 24 hours. 2. Excess fluid volume related to medication therapy, manifested by 5 pound weight gain and leg edema. 3. Excess fluid volume related to adverse effects of medications, as evidenced by unknown etiology. 4. Risk for fluid volume imbalance related to adverse effects of medications.

2. Excess fluid volume related to medication therapy, manifested by 5 pound weight gain and leg edema.

When is the nurse supposed to use the evaluation step of the nursing process? 1. Upon admission 2. When the patient is ready for discharge 3. After each intervention 4. During the review of patient education

3. After each intervention

The nurse uses which step of the nursing process to detect any potential complications? a. Assessment b. Planning c. Nursing diagnosis d. Implementation

a. Assessment

Nurse perform the task of patient assessment to determine: (Select all that apply.) a. the patient's response to treatments. b. any adverse effects of medications. c. the status of their discharge. d. if the medical diagnosis is correct. e. if the patient has any risk factors.

a. the patient's response to treatments. b. any adverse effects of medications. e. if the patient has any risk factors.

Important healthcare information that the nurse gathers during the assessment of a patient includes which component(s)? (Select all that apply.) a. vital signs b. lung sounds c. mobility level d. discharge plans e. family support

a. vital signs b. lung sounds c. mobility level

The nurse considers the patient's psychological and cultural needs during which step of the nursing process? a. Assessment b. Planning c. Nursing diagnosis d. Implementation

b. Planning

The nurse is supposed to perform postoperative teaching for a patient who is scheduled to be discharged the next day. The patient appears fatigued, in pain, and irritable. The nurse knows that there will be little time for teaching on the day of discharge. What is the nurse's best course of action? a) Deliver the teaching now because there won't be enough time tomorrow. b) Allow the patient to nap, and return to perform the teaching in 1 hour. c)Teach the family member who is present, so he or she can share the information with the patient after discharge. d)Determine the patient's need for analgesia and rest, and return to perform the teaching after the patient feels better.

d)Determine the patient's need for analgesia and rest, and return to perform the teaching after the patient feels better.

What does NANDA stand for when referring to nursing diagnoses? a. Not All Nursing Diagnosis Association b. Natural Accented Northern Diagnostic Adaptable c. Nursing Accountable Nursing Diagnosis Authority d. Northern American Nursing Diagnosis Association

d. Northern American Nursing Diagnosis Association

Which level of Maslow's hierarchy would be a priority when planning nursing care? a. Safety needs b. Belonging needs c. Self-esteem needs d. Physiologic needs

d. Physiologic needs

Nurses use the nursing process to: a. build a framework for consistent nursing actions. b. assign nursing staff to patients. c. standardize the language nurses use to analyze nursing care. d. solve problems in nursing systematically.

d. solve problems in nursing systematically.

Which piece of information obtained during a patient assessment is a subjective finding? a)Patient states, "I have pain in my abdomen." b)Temperature of 38.5° C c)400 mL of clear, yellow urine d)Blood pressure of 116/74 mm Hg

Answer: a (Patient states, "I have pain in my abdomen.") Rationale: A subjective finding is one that the nurse makes using physiologic parameters. A patient's report of pain is a subjective finding because people experience pain differently. An objective assessment is clearly measurable and consistently reportable.

What is the foundation for the clinical practice of nursing? a)Assessment b)Nursing process c)Planning d)Evaluation e)Implementation

Answer: b (Nursing process) Rationale: It takes all parameters of the nursing process, which include assessment, diagnosis, planning, implementation, and evaluation, to encompass the full care of a patient.

An older adult patient is being prepared for discharge after experiencing a stroke with some residual damage. The patient and family are scheduled to receive a large amount of information from the nurse regarding proper care and safety at home. What is the nurse's best course of action? a) Present the patient and family with all of the information a few days before discharge. b) Present the patient and family with all of the information the day before discharge. c) Break the teaching content down into manageable sections and present them individually in the days before discharge. d) Have a home health nurse teach the patient and family at home a week after discharge.

Answer: c (Break the teaching content down into manageable sections and present them individually in the days before discharge.) Rationale: Discharge teaching is an ongoing process and should not wait until the patient is ready to go home. The patient and family need to learn about home care before discharge, and the content should be presented in small sections and repeated as necessary because repetition en

The nurse who is new to a large urban hospital has found that many of the hospitalized patients are of different cultural groups in the area. Which approach is best for the nurse to take in caring for these patients? a)Care for all patients the same way because it is more efficient. b)Ask not to be assigned to these patients due to the nurse's lack of experience. c) Develop a plan of care that is individualized to each patient's needs. d) Follow a more experienced nurse around for several months to gain more experience.

Answer: c (Develop a plan of care that is individualized to each patient's needs.) • Rationale: Nurses must be prepared to care for patients from different cultures and develop an awareness of and respect for cultural diversity. Many resources are available for education, and this should be a part of the orientation of new nurses. The nurse may find that asking individuals about preferences is helpful and respectful.

The nurse is preparing to teach a postsurgical patient who has a new colostomy about proper colostomy care. The patient says, "Just show me how to do it; let me try, and I'll learn what to do." Which domain of learning is indicated by this statement? a)Cognitive b) Affective c)Psychomotor d)Determined

Answer: c (Psychomotor) Rationale: The patient's willingness to see, hear, and do indicates a learning style in the psychomotor, or "doing," domain. Demonstration of the skill with a step-by-step, hands-on approach is usually the best way for this type of learner to be trained in a new skill.

The nurse is supposed to perform postoperative teaching for a patient who is scheduled to be discharged the next day. The patient appears fatigued, in pain, and irritable. The nurse knows that there will be little time for teaching on the day of discharge. What is the nurse's best course of action? a) Deliver the teaching now because there won't be enough time tomorrow. b)Allow the patient to nap, and return to perform the teaching in 1 hour. c)Teach the family member who is present, so he or she can share the information with the patient after discharge. d)Determine the patient's need for analgesia and rest, and return to perform the teaching after the patient feels better.

Answer: d (Determine the patient's need for analgesia and rest, and return to perform the teaching after the patient feels better.) • Rationale: After the patient's basic needs are assessed and met, he or she will be better able to focus on the educational material and be prepared for discharge. It is important for the patient to verbally demonstrate learning as well as perform any skill autonomously.

Which is an independent nursing action? a)Orders medications based on the patient's medical diagnosis b)Orders laboratory tests depending on the medications ordered c)Chooses an alternate route for medications if indicated d)Verifies the correct route of medication administration

Answer: d (Verifies the correct route of medication administration) Rationale: Verification of the correct route of administration is an independent nursing action that is required as part of the "seven rights" of administration. Ordering drugs or labs and changing a route of administration are not within the scope of practice for a nurse.

NANDA diagnoses are part of the nursing language that describes which types of diagnoses? (Select all that apply.) a. Syndrome nursing diagnoses (Ex: Disuse syndrome) b. Actual medical diagnoses C. Risk/high-risk nursing diagnoses (Ex: High-risk for fall) d. Wellness nursing diagnoses (Ex: Readiness for enhanced community coping) e. Health promotion diagnoses

a. Syndrome nursing diagnoses (Ex: Disuse syndrome) C. Risk/high-risk nursing diagnoses (Ex: High-risk for fall) d. Wellness nursing diagnoses (Ex: Readiness for enhanced community coping) e. Health promotion diagnoses

The nurse needs to assess the patient in the hospital for the therapeutic effects, side effects, and potential drug interactions during which time? a. Throughout hospitalization b. When the patient has visitors c. When the patient request for a PRN medication d. When monitoring vital signs

a. Throughout hospitalization

The five levels of needs identified by Maslow's hierarchy include: (Select all that apply.) a. self-actualization. b. safety. c. belonging. d. physiologic. e. priority

a. self-actualization. b. safety. c. belonging. d. physiologic.

How does a nursing diagnosis differ from a medical diagnosis? a)A nursing diagnosis concerns a disease that impairs physiologic function. b)A nursing diagnosis evaluates a patient's response to actual or potential health problems. c)A nursing diagnosis determines the rate of Medicare reimbursement. d)A nursing diagnosis does not consider potential future problems.

b (A nursing diagnosis evaluates a patient's response to actual or potential health problems.) • Rationale: A nursing diagnosis takes the form of a three-part statement relating to a patient's response to actual or potential health problems and life processes. It is constantly changing, whereas a medical diagnosis is frequently unchanged during a patient's hospitalization.

An important aspect of the nursing process is that it uses which approach? a. Intuitive b. Problem-solving C. Scientific d. Analytical

b. Problem-solving

A clinical judgment that a person is more susceptible to a particular problem than others in the same situation is defined as which type of nursing diagnosis? a)Actual b)Health promotion/wellness c)Risk/high risk d)Syndrome

c (Risk/high risk) Rationale: A risk/high-risk nursing diagnosis is supported by risk factors that increase a patient's vulnerability beyond that of the same population. The patient can be at risk or at high risk for a particular problem.

The nurse is preparing a patient for discharge after a surgical procedure. Which method is best for teaching the patient about his or her prescribed drugs? a) Prescription blank handwritten by the physician b)Magazine ads featuring the prescribed medications c)Verbal explanations along with drug summary sheets d)Unit-dose packages from this morning's medications

c (Verbal explanations along with drug summary sheets) Rationale: Typically, verbal explanations are best as long as the patient is able to hear adequately. Drug summary sheets are prepared at a reading level appropriate for most people. Prescription forms are not a good teaching tool for medications; patients typically don't get to keep prescription forms after filling them at the pharmacy. Unit-dose packages are inappropriate because they may not represent the same manufacturer of the drugs that the patient will be taking, which may lead to confusion.