Fundamentals: Quiz #2

The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?N

"Begin with the highest priority diagnoses, then select appropriate interventions."

A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

"Do you feel like you need to go to the bathroom?"

A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate?

"Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals."

Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?

"How many bowel movements a day have you had?"

A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?

"I'll wear the blue dress. It matches my eyes."

A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?

"Nurses use evaluation to determine the effectiveness of nursing care."

A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided?

"This system can help medical students determine the cost of the care they provide to patients."

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions?

- Ambulating a patient - Inserting a feeding tube - Performing resuscitation - Teaching about medications

Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)

- Determine whether outcomes or standards are met. - Document results of goal achievement. - Use self-reflection and correct errors.

A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)

- Equipment - Safe environment - Assistive personnel

A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)

- Impaired physical mobility related to incisional pain - Nausea related to adverse effect of cancer medication

A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient's responses to nursing care? (Select all that apply.)

- Observations of wound healing - Daily blood pressure measurements - Findings of respiratory rate and depth - Patient's subjective report of feelings about a new diagnosis of cancer

Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)

- Perform dressing changes twice a day as ordered. - Teach the patient about signs and symptoms of infection. - Instruct the family about how to perform dressing changes. - Administer medications to control the patient's blood sugar as ordered.

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)

- Rank all the patient's nursing diagnoses in order of priority. - Consider time as an influencing factor. -Utilize critical thinking.

A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)

- Reposition a patient who is on bed rest. - Teach a patient preoperative exercises. - Transfer a patient to another hospital unit.

1. Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.)

- Tense muscles - Reactive responses - Trouble concentrating - Very tired feelings

A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma 2. Writes a diagnostic label of impaired gas exchange 3. Organizes data into meaningful clusters 4. Interprets information from patient 5. Writes an etiology

1, 3, 4, 2, 5

A nurse is preparing to make a consult. In which order, beginning with the first step, will the nurse take? 1. Identify the problem. 2. Discuss the findings and recommendation. 3. Provide the consultant with relevant information about the problem. 4. Contact the right professional, with the appropriate knowledge and expertise. 5. Avoid bias by not providing a lot of information based on opinion to the consultant.

1, 4, 3, 5, 2

The nurse is revising the care plan. In which order will the nurse perform the tasks, beginning with the first step? 1. Revise specific interventions. 2. Revise the assessment column 3. Choose the evaluation method. 4. Delete irrelevant nursing diagnoses.

2, 4, 1, 3

In which order will the nurse use the nursing process steps during the clinical decision- making process? 1. Evaluating goals2. Assessing patient needs3. Planning priorities of care4. Determining nursing diagnoses5. Implementing nursing interventions

2, 4, 3, 5, 1

A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis. 2. Reassess blood pressure reading. 3. Retake blood pressure after medication. 4. Administer new blood pressure medication. 5. Change goal to blood pressure less than 140/90.

2,1,5,4,3

A nurse is prioritizing care for four patients. Which patient should the nurse see first?

A patient with difficulty breathing

A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?

Abdominal distention

The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?

Absence of skin breakdown

A staff nurse delegates a task to a nursing assistive personnel (NAP), knowing that the NAP has never performed the task before. As a result, the patient is injured, and the nurse defensively states that the NAP should have known how to perform such a simple task. Which element of the decision-making process is the nurse lacking?

Accountability

Which action should the nurse take to best develop critical thinking skills?

Actively participate in clinical experiences.

2. Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?

Acute pain

A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which isthe most pertinent nursing diagnosis the nurse will include in the plan of care?

Acute pain

While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take?

Adapt the positioning technique to the situation.

A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)

Adds objectivity to judging a patient's progress Measures nursing care on a national and international level

A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?

Administer pain medication.

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

Administer the acetaminophen.

A patient with an indwelling urinary catheter has been given a bed bath by a new nursing assistive personnel. The nurse evaluating the cleanliness of the patient notices crusting at the urinary meatus. Which action should the nurse take next?

Ask the nursing assistive personnel to observe while the nurse performs catheter care.

The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation?

Ask the patient about the crying.

A patient visiting with family members in the waiting area tells the nurse "I don't feel good, especially in the stomach." What should the nurse do?

Ask the patient to return to the room, so the nurse can inspect the abdomen.

A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility?

Asking for an orientation to the unit

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past

Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's firstaction?

Assess the patient for other symptoms or problems, and then notify the health care provider.

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall.Which initial action will the nurse take next to revise the plan of care?

Assess the patient.

The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?

Assesses the patient's readiness for the procedure

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error?

Assessment

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing dignosis statement Risk for falls?

Assist patient into and out of bed every 4 hours or as tolerated.

A staff member verbalizes satisfaction in working on a particular nursing unit because of the freedom of choice and responsibility for the choices. This nurse highly values which element of shared decision making?

Autonomy

A nurse is overseeing the care of patients with severe diabetes and patients with heart failure to improve cost-effectiveness and quality of care. Which nursing care delivery model is the nurse using?

Case management

A nurse manager discovers that the readmission rate of hospitalized patients is very high on the hospital unit. The nurse manager desires improved coordination of care and accountability for cost-effective quality care. Which nursing care delivery model is best suited for these needs?

Case management

Which action will the nurse take after the plan of care for a patient is developed?

Communicate the plan to all health care professionals involved in the patient's care.

Which approach will be most appropriate for a nurse to take when faced with the challenge of performing many tasks in one shift?

Complete one task before starting another task.

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs?

Concept mapping

Which action should the nurse take when using critical thinking to make clinical decisions?

Consider what is important in a given situation.

The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?

Counseling about respite care options

A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation?

Creativity

A nurse is working in a facility that has fewer directors with managers and staff able to make shared decisions. In which type of organizational structure is the nurse employed?

Decentralization

A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document?

Decreased cardiac output related to altered myocardial contractility.

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?

Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?

Deficient fluid volume

A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?

Dependent

Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?

Determines whether an intervention is correct and appropriate for the given situation

A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?

Develop good communication skills.

A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?

Developing nursing diagnoses before completing the database

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?

Diagnostic reasoning

A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?

Disruption of tissue integrity

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Etiology

A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient's plan of care?

Evaluate whether patient goals and outcomes have been met.

A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next?

Evaluation

A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?

Evaluation

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first?

Explore other options for pain relief.

A nursing assistive personnel (NAP) reports seeing a reddened area on the patient's hip while bathing the patient. Which action should the nurse take?

Go to the patient's room to assess the patient's skin.

A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate?

Health behavior

A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catherization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?

Health promotion

A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met?

Heart rate 78 beats/min on 12/3

A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene?

Hemorrhage

A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient?

Identify factors interfering with goal achievement.

A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?

Impaired gas exchange related to alveolar-capillary membrane changes

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan?

Impaired skin integrity

A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?

Implementation

Which action indicates the nurse is using a PICOT question to improve care for a patient?

Implements interventions based on scientific research

Which action demonstrates a nurse utilizing reflection to improve clinical decision making?

Improves a plan of care while thinking back on interventions effectiveness

A hospital's wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient's dressing changes. Which action should the nurses take next?

Include dressing change instructions and frequency in the care plan.

A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following?

Institutional practice guidelines

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?

Interdependent

The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?

Interpersonal

The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill?

Interpretation

A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?

Involve the son in the plan of care as much as possible.

Which information indicates a nurse has a good understanding of a goal?

It is a broad statement describing a desired change in a patient's behavior.

A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?

Lungs clear to auscultation following use of inhaler

A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene?

Making a clinical decision based on previous shift assessments

The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take?

Measure the wound and observe for redness, swelling, or drainage.

A nurse is making a home visit and discovers that a patient's wound infection has gotten worse. The nurse cleans and redresses the wound. What should the nurse do next?

Notify the health care provider of the findings before leaving the home.

A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise?

Nurse's assumptions about hospital discharge

Which staff member does the nurse assign to provide morning care for an older-adult patient who requires assistance with activities of daily living?

Nursing assistive personnel (NAP)

A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?

Observe wound appearance and edges.

A new nurse expresses frustration at not being to complete all interventions for a group of patients in a timely manner. The nurse leaves the rounds report sheets at the nurse's station when caring for patients and reports having to go back and forth between rooms for equipment and supplies. Which type of skill does the nurse need?

Organizational

A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion?

Patient correctly states names of family members in the room.

Which assessment of a patient who is 1 day postsurgery to repair a hip fracture requires immediate nursing intervention?

Patient reports severe pain 30 minutes after receiving pain medication.

A nurse is assigned to care for the following patients who all need vital signs taken right now. Which patient is most appropriate for the nurse to delegate vital sign measurement to the nursing assistive personnel (NAP)?

Patient scheduled for a procedure in the nuclear medicine department

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

Patient will have one soft, formed bowel movement by end of shift.

A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?

Patient will increase activity level this shift.

A nurse manager conducts rounds on the unit and discovers that expired stock medicine is still in the cabinet despite the e-mail that was sent stating that it had to be discarded. The staff nurse dress code is not being adhered to as requested in the same e-mail. Several staff nurses deny having received the e-mail. Which action should the nurse manager take?

Place a hard copy of announcements and unit policies in each staff member's mailbox.

The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?

Planning

The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?

Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions.

A nurse is reviewing a patient's care plan. Which information will the nurse identify as a nursing intervention?

Provide assistance while the patient walks in the hallway twice this shift with crutches.

A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to verbal communication?

Provide the patient with a writing board each shift.

The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using?

Psychomotor

A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?

Reassess the patient and situation.

After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is priority for this patient?

Reassess the patient's pain level in 30 minutes.

Which action should the nurse take first during the initial phase of implementation?

Reassess the patient.

Which initial intervention is most appropriate for a patient who has a new onset of chest pain?

Reassess the patient.

A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?

Reflex urinary incontinence

A nurse is using the critical thinking skill of evaluation. Which action will the nurse take?

Review the effectiveness of nursing actions.

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

Review the patient's activity orders.

The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action?

Revise the plan of care and change the dressing now.

A nurse uses the five rights of delegation when providing care. Which "rights" did the nurse use? (Select all that apply.)

Right task Right person Right direction Right supervision Right circumstances

A nurse is using a critical thinking model to provide care. Which component is first that helps a nurse make clinical decisions?

Specific knowledge base

A nurse manager sent one of the staff nurses on the unit to a conference about new, evidence- based wound care techniques. The nurse manager asks the staff nurse to prepare a poster to present at the next unit meeting, which will be mandatory for all nursing staff on the unit. Which type of opportunity is the nurse manager providing for the staff?

Staff education

A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?

States feels better after talking with family and friends

Which action indicates a registered nurse is being responsible for making clinical decisions?

Takes immediate action when a patient's condition worsens

The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?

Teaches proper handwashing technique

A registered nurse (RN) is the group leader of practical nurses and nursing assistive personnel. Which nursing care model is the RN using?

Team nursing

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

The patient is able to ambulate in the hallway with crutches.

A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?

The patient will feed self at all mealtimes today without reports of shortness of breath.

The following statements are on a patient's nursing care plan. Which statement will the nurse use as an outcome for a goal of care?

The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions?

To distinguish the nurse's role from the physician's role

A nurse is working in an intensive care unit (critical care). Which type of nursing care delivery model will this nurse most likely use?

Total patient care

A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?

Turn the patient every 2 hours, even hours.

A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions?

Uses critical thinking for the highest level of quality nursing care

Which action by a nurse indicates application of the critical thinking model to make the bestclinical decisions?

Using the nursing process

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

diagnosis