FUNds 321 chapter 18

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 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 describes an independent nursing intervention? Select all that apply. One, some, or all responses may be correct.

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

Which factor would be considered when choosing a nursing intervention to address a patient problem? Select all that apply. One, some, or all responses may be correct.

--Outcomes that have been set for the patient --Research evidence supporting the intervention --Capabilities of the nurse --Characteristics of the nursing diagnosis

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

1. REDUCED OXYGENATION 2. THREAT OF IMMOBILITY 3. POOR HEALTH MANAGEMENT 4. POSSIBLE ISOLATION FROM THE COMMUNITY

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 when, right before starting the intravenous (IV) line, the patient needs to void (urinate)?

Assist the patient to the bathroom.

Which option correctly describes a nurse's actions? Select all that apply. One, some, or all responses may be correct.

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 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? Select all that apply. One, some, or all responses may be correct.

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 priority action would the nurse take before administering a new drug?

Consult with a pharmacist to obtain knowledge about the medication.

Which action would be an example of a collaborative intervention?

Consult with dietitian on initial foods to offer patient.

Which direct care measure would the nurse be using when consulting with the dietitian and health care provider to determine the initial rate that will be prescribed for the tube feeding to lessen the chance of diarrhea?

Controlling for an adverse reaction

Which criterion is used to evaluate efficacy of interventions?

Expected outcome

Which category is a type of nursing intervention? Select all that apply. One, some, or all responses may be correct.

INTERDEPENDENT NURSE-INITIATED HEALTH CARE PROVIDER-INITIATED

Which type of problem is a high priority?

One related to life-threatening needs of the patients

When assessing a patient with a terminal illness, the nurse notes the patient's monosyllabic replies and limited eye contact. Which direct care intervention does the nurse perform?

Providing counseling

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

Psychomotor

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 would be appropriate for a postoperative patient who is on bed rest and at risk of skin injuries after surgery? Select all that apply. One, some, or all responses may be correct.

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

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? Select all that apply. One, some, or all responses may be correct.

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

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

SECONDARY

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 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 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.

Which information about standing orders is accurate? Select all that apply. One, some, or all responses may be correct.

They are preprinted documents that contain orders for various clinical problems. They provide legal protection to the nurse when caring for the patient. They are signed by the licensed prescribing health care provider in charge at the time of implementation.

Which intervention indicates the nurse is delivering ethical care?

Understanding the patient's expectations

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

high

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

timed

The family of a patient states, "We found out that our loved one has end-stage hepatitis. We don't know what that means." How does the nurse respond?

Asking about the family's understanding of the patient's illness

Which type of nursing intervention is an interdependent intervention?

COLLABORATIVE

Which information accurately describes a physical care technique? Select all that apply. One, some, or all responses may be correct.

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

Which action would the nurse take during consultations?

Avoid bias by not sharing subjective and emotional conclusions.

Which guideline would the nurse use to counsel a patient and family members about coping? Select all that apply. One, some, or all responses may be correct.

1. Assist them to accept a change in health status. 2. Provide emotional and psychological support. 3. Assist the patient and family in managing stress. 4. Understand that a patient requiring nursing counseling has normal adjustment difficulties and may be upset or frustrated.

Place the steps of consultation in the correct sequence.

1. Identify the problems associated with the patient 2. Direct the consultation to the right professional. 3. Provide the consultant with relevant information about the problem area. 4. Be available to discuss the consultant's findings and recommendations. 5. Incorporate the consultant's recommendations into the care plan.

How many classes are included in the second level of the Nursing Interventions Classification (NIC) model? Record your answer using a whole number. ________

30

Which factor would the nurse consider when making discharge plans for activities of daily living (ADLs)? Select all that apply. One, some, or all responses may be correct.

A 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 feature is true about standing orders?

Allow a quick response to a rapidly changing clinical situation.

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

Keep some extra supplies handy

Which patient outcome about a wound would allow the nurse to measure a patient's response to care more precisely?

Will reduce in size to less than 4 cm (1.5 inches) by day 4.

Which patient problem would be a high priority?

chest pain

Which activity is classified as an instrumental activity of daily living (IADL)? Select all that apply. One, some, or all responses may be correct.

SHOPPING HOUSE CLEANING PREPARING MEALS

Place the steps in proper order for modifying the plan of care when a patient develops nausea after chemotherapy.

1. Enter data in the assessment column showing new information about the patient's nausea. 2. Add the current patient condition of nausea as a nursing diagnosis. 3. Select approaches for controlling environmental factors that worsen nausea. 4. Decide to use the patient's self-report of appetite and fluid intake as evaluation measures.

Which component would be included in a comprehensive nursing care plan? Select all that apply. One, some, or all responses may be correct.

1. NURSING DIAGNOSES 2. EXPECTED OUTCOMES 3. EVALUTION FINDINGS

Which sequence would the nurse follow for making decisions about implementing interventions?

1. Review all possible interventions for the patient 2. Review all possible consequences associated with each intervention. 3. Determine the probability of possible consequences. 4. Judge the value of the consequences to the patient.

Which expected outcome is correctly written and would be appropriate for a patient who must have surgery for a knee injury? Select all that apply. One, some, or all responses may be correct.

1. The patient describes the purpose of surgery after talking to the surgeon. 2. The patient discusses the surgical outcomes with the surgeon in 24 hours. 3. The patient describes activity restrictions to follow by discharge in 48 hours.

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

1. The patient's vital signs change, showing a drop in blood pressure. 2. The patient expresses concern about pain Correct 3. The family comes to visit the patient. Correct 4. The charge nurse approaches the nurse and requests a report at end of shift.

Which action would the nurse take when unable to perform a complex intervention successfully?

Ask for assistance from an experienced nurse.

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 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 action would be classified as a health care provider-initiated intervention? Select all that apply. One, some, or all responses may be correct.

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

The nurse provides postoperative care for a patient and notes a slightly elevated temperature. Which intervention demonstrates the nurse's understanding of evidence-based practice?

Implementing a care bundle

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

Manage the patient's environment.

Which information would the nurse share with the patient when starting an intravenous (IV) medication? Select all that apply. One, some, or all responses may be correct.

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 feature is typical of an intermediate priority nursing diagnosis?

Nonemergent

Which characteristic is a component of well-written goals and expected outcomes? Select all that apply. One, some, or all responses may be correct.

OBSERVABLE TIMED PATIENT-SPECIFIC

Which action is an example of an independent nursing intervention? Select all that apply. One, some, or all responses may be correct.

Provide health education Assist with daily activities Reposition a patient

Which intervention performed by the nurse is an independent nursing intervention? Select all that apply. One, some, or all responses may be correct.

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

Which expected outcome is correctly written? Select all that apply. One, some, or all responses may be correct.

--The patient describes two signs of urinary obstruction within 24 hours. --The patient identifies three signs and symptoms of wound infection before surgery.

Which action would the nurse take before implementing health care provider-initiated interventions? Select all that apply. One, some, or all responses may be correct.

-Clarify questionable prescriptions -Decide if the intervention is appropriate for the patient. -Determine if collaboration with other care disciplines is required.

Which nurse-initiated intervention would the nurse perform to help an anxious male patient express acceptance of his health status? Select all that apply. One, some, or all responses may be correct.

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

Which capability of the nurse would help in choosing suitable nursing interventions? Select all that apply. One, some, or all responses may be correct.

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

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? Select all that apply. One, some, or all responses may be correct.

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

Which action is classified as an indirect care measure? Select all that apply. One, some, or all responses may be correct.

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 action performed for the patient is a nurse-initiated intervention? Select all that apply. One, some, or all responses may be correct.

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

Which action does the nurse take right before implementing interventions?

Reassess the patient.

Which element is a chief component of the nursing process? Select all that apply. One, some, or all responses may be correct.

DIAGNOSIS ASSESSMENT IMPLEMENTATION

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 nursing-sensitive patient outcome is a component of quality health care? Select all that apply. One, some, or all responses may be correct.

Incidence of pressure injuries Number of patient falls

A home-health nurse provides palliative care for a patient in a community setting. The patient states, "The pain pills that I have been taking are not as effective as they used to be." After reviewing the patient's standing orders, which action does the nurse take?

Increases the medication dosage

Which action is an example of a dependent nursing intervention? Select all that apply. One, some, or all responses may be correct.

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

Which action would the nurse take when arranging supplies and equipment before administering an intravenous (IV) antibiotic to a patient? Select all that apply. One, some, or all responses may be correct.

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

Which activity would the nurse perform when preparing for the implementation phase of the nursing process? Select all that apply. One, some, or all responses may be correct.

Reassessing the patient Organizing resources and care delivery Reviewing and revising the existing nursing care plan

Which information would the nurse include in a teaching session about the levels of prevention? Select all that apply. One, some, or all responses may be correct.

Primary prevention involves immunizations, health education programs, nutrition, and physical activities. Secondary prevention involves early diagnosis and prompt treatment. Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation. Secondary prevention focuses on people who are experiencing health problems or illnesses.

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 intervention would the nurse perform for a patient who has developed a hypersensitivity reaction to penicillin and has developed hives? Select all that apply. One, some, or all responses may be correct.

Record the reaction Inform the health care provider Administer diphenhydramine, as prescribed. Reassure the patient.

The nurse reviews potential interventions for a patient who is experiencing pain. When considering the administration of an analgesic, the nurse identifies that the medication may cause an adverse reaction, including increasing the patient's fall risk. The nurse is demonstrating which principle of critical judgment and decision-making?

Review all possible consequences associated with each possible nursing action.

Which initial action would the nurse take when a patient's symptoms have changed from those that were recorded earlier?

Revise patient data by noting the change.

Which statement is true about discharge planning? Select all that apply. One, some, or all responses may be correct.

--Start discharge planning at admission. --Involve family members in discharge planning.

Which intervention would the nurse add to the nursing care plan to reduce anxiety in a patient? Select all that apply. One, some, or all responses may be correct.

--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 characteristic of nursing goals and expected outcomes would the nurse keep in mind when developing a care plan? Select all that apply. One, some, or all responses may be correct.

--REALISTIC --ATTAINABLE --SPECIFIC TO PATIENT

Which problem is considered a high priority for a patient? Select all that apply. One, some, or all responses may be correct.

--Reduced oxygenation --Insufficient circulation

Which resource would the nurse use to develop a plan of care? Select all that apply. One, some, or all responses may be correct.

--Scientific literature --Standard protocols --Procedure manuals --Nursing Interventions Classification

Which process is involved in the planning phase of the nursing process? Select all that apply. One, some, or all responses may be correct.

--Setting priorities --Prescribing nursing interventions --Identifying patient-centered goals

Which intervention performed by the nurse is an interdependent intervention? Select all that apply. One, some, or all responses may be correct.

---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 function would the nurse add to the care plan for a patient in the home? Select all that apply. One, some, or all responses may be correct.

---Include the nurse's evaluation of expected outcomes. ---Educate the patient about necessary care techniques. ---Teach the family to integrate care within family activities.

Which tip would be helpful when a nurse is making a phone consultation? Select all that apply. One, some, or all responses may be correct.

--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 intervention performed by the nurse would require an order from a health care provider? Select all that apply. One, some, or all responses may be correct.

--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 nursing intervention is correctly written and the nurse would add to the plan of care? Select all that apply. One, some, or all responses may be correct.

--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 major component would be included in a nursing care plan? Select all that apply. One, some, or all responses may be correct.

--NURSING DIAGNOSES --SPECIFIC NURSING INTERVENTIONS --GOALS AND EXPERCTED OUTCOMES

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? Select all that apply. One, some, or all responses may be correct.

--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 factor would the nurse consider before setting a goal that the patient will self-administer insulin injections? Select all that apply. One, some, or all responses may be correct.

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

Which action is an example of an independent nursing intervention? Select all that apply. One, some, or all responses may be correct.

-Provide health education -Assist with daily activities -Reposition a patient

Which nursing intervention is an example of direct care for a patient? Select all that apply. One, some, or all responses may be correct.

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

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 expected outcome is written in measurable terms?

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

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

Patient's skin will remain intact through discharge.

Which type of action would describe a nurse performing cardiopulmonary resuscitation (CPR) for a patient in cardiac arrest? Select all that apply. One, some, or all responses may be correct.

DIRECT CARE LIFESAVING MEASURE

Which category is a level of the Nursing Interventions Classification (NIC) model? Select all that apply. One, some, or all responses may be correct.

DOMAIN CLASSES INTERVENTIONS

Which activity is the third step in the five-step nursing process?

PLANNING

Which level of prevention describes a nurse administering a vaccine to an infant?

PRIMARY

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

PRIMARY

Which patient care goal is a long-term goal for a newly diagnosed medically unstable patient with diabetes?

Patient will achieve glucose control

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.

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

When the patient is expected to respond in the desired manner