NCLEX STYLE REVIEW QUESTIONS FOR NURSE PROCESS, LEGAL, PROFESSIONALISM, AND ETHICS

Secondary sources of information include (select all that apply): Medical record Patient Physician Spouse or close relative

Medical record Spouse or close relative

The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? Risk for aspiration Acute confusion Readiness for enhanced coping Sedentary lifestyle

Risk for aspiration A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.

Which outcome allows you to measure a patient's response to care more precisely? The patient's wound will appear normal within 3 days. The patient's wound will have less drainage within 72 hours. The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4. The patient's wound will heal without redness or drainage by day 4.

he patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4. An outcome must have terms describing quality, quantity, frequency, length, or weight to allow for precise measurement. The statement "The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4" identifies a specific wound size, which indicates a degree of healing. The outcome statements concerning the wound appearing normal and having less drainage are vague and not measurable. The statement "The patient's wound will heal without redness or drainage by day 4" has more than one outcome.

The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case the finding of nausea is which of the following? An objective finding A clinical inference A validation A concomitant symptom

A concomitant symptom A concomitant symptom is a symptom that occurs along with a primary symptom. The finding is subjective based on patient self-report. There is no clinical inference since the nurse is not trying to find the meaning of the findings. The patient is reporting nausea, but there is no validation or confirmation with another source.

A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply.) A problem-focused approach A structured comprehensive approach Using multiple visits to gather a complete database Focusing on the functional health pattern of role-relationship

A problem-focused approach The nurse should use a focused approach initially to determine the patient's respiratory status. However, to gather an admission assessment, multiple visits are needed because of the patient's age and level of physical distress. A structured comprehensive approach is not appropriate for this acute situation. Eventually the nurse will want to assess the patient's role-relationship health pattern because of his wife's death. But it is not appropriate at this time.

The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? (Select all that apply.) Vital sign results Abdominal distention Age of patient Change in bowel elimination pattern Abdominal pain No past history of hospitalization

Abdominal distention Change in bowel elimination pattern abdominal pain The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster, suggesting an elimination problem

What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply.) Active listening Back channeling Validating Use of open-ended questions Use of closed-ended questions

Active Listening, Back Channeling, Use of open ended questions Active listening allows the patient to speak and shows the nurse's respect for what he or she has to say. Back channeling reinforces interest in what the patient has to say and shows the nurse's desire to hear the full story. Using open-ended questions encourages the patient to tell his or her story and actively describe his or her health status. Validation simply confirms accuracy of data collected. Closed-ended questions do not encourage storytelling.

When does implementation begin as the fourth step of the nursing process? During the assessment phase Immediately in some critical situations After the care plan has been developed After there is mutual goal setting between nurse and patient

After the care plan has been developed Implementation begins after the nurse has developed the plan of care. Even in emergent situations a nurse assesses a situation quickly, considers options, and then implements nursing measures. Goal setting is part of planning.

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) Anxiety related to fear of dying Fatigue related to chronic emphysema Need for mouth care related to inflamed mucosa Risk for infection

Anxiety related to fear of dying Risk for infection The diagnosis Anxiety related to fear of dying is stated correctly, with the related factor being the patient's response to a health problem. Risk for infection is a risk factor for an at-risk diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventive measures. Fatigue related to chronic emphysema is incorrect since chronic emphysema is a medical diagnosis. Need for mouth care related to inflamed mucosa is not a NANDA-I approved nursing diagnosis.

The registered nurse (RN), who is supervising a group of nurses at a health clinic, overhears a nurse telling a patient, "If you do not stop shouting, I am going to give you an injection." The RN immediately intervenes and tells the nurse this action can lead to which accusation? Delegation Breach of confidentiality Assault Respondeat superior

Assault Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Breach of confidentiality is revealing health care information to those not involved with the care of the patient. Delegation involves giving someone else authority to act for another. Respondeat superior attributes the acts of the employees to their employer.

A nurse informs the patient's health care provider that the patient is refusing potentially life saving surgery. In this situation, which ethical principle is the nurse using? Beneficence Nonmaleficence Autonomy Justice

Autonomy Using the principle of autonomy allows individuals to have the right to determine their own actions and make their own choices. Calling the health care provider to report the patient's refusal of surgery demonstrates the nurse's use of autonomy to guide practice. Beneficence is frequently described as "the doing of good." Nonmaleficence is the duty to do no harm. A description of justice includes patients with the same diagnosis and health care needs receiving the same care.

What type of interview techniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply.) Active listening Open-ended questioning Closed-ended questioning Problem-oriented questioning

Closed-ended questioning Problem-oriented questioning The nurse's technique is to ask a closed-ended question using a problem oriented approach. The patient gives a specific answer to broaden the nurse's knowledge about the character of his pain.

Before consulting with a physician about a patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? Cognitive Interpersonal Psychomotor Consultative

Cognitive Thinking and anticipating how to approach implementation involve a cognitive implementation skill. The nurse considers the rationale for an intervention and evidence in nursing science that supports that intervention or alternatives.

The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview? Setting the stage Gathering information about the patient's chief concerns Collecting the assessment Termination

Collecting the assessment The nurse is focusing on the patient's nutritional status and asking specific questions to assess his diet history.

Which of the following nursing orders is written correctly for the diagnosis of: Acute pain r/t deep vein thrombosis m/b redness, swelling, warmth, positive Homans'? Assess level of pain. Complete bed rest with right leg elevated on two pillows at all times. Monitor lab values. Assess vital signs.

Complete bed rest with right leg elevated on two pillows at all times. This nursing order includes what to do, when, and how often.

Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is: Need for improved bowel function related to change in diet. Patient needs improved bowel function related to alteration in elimination. Constipation related to inadequate fluid intake. Constipation related to hard infrequent stools.

Constipation related to inadequate fluid intake. Constipation related to inadequate fluid intake is an accurate NANDA-I approved nursing diagnosis with an appropriate etiology. Need for improved bowel function related to change in diet is a goal with an etiologic factor. Patient needs improved bowel function related to alteration in elimination is a goal with a diagnostic statement. Constipation related to hard infrequent stools is a nursing diagnostic label with a clinical sign.

A nurse checks a physician's order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. A nurse colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. The nurse's best action before giving the medication is to: Have the nurse colleague check the dose with her before giving the medication. Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects. Ask the nurse colleague to administer the medication to her patient. Administer the medication as prescribed and on time.

Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects. When a nurse performs a new or unfamiliar procedure, such as giving a new medication, it is important to assess personal competency and determine if new knowledge or assistance is needed. The nurse's best action is to check with the pharmacist about the medication. Having another nurse check the dosage is appropriate if the nurse is still uncertain about the medication. Once the nurse feels prepared, the medication is administered as prescribed. You never ask a colleague to give a medication to a patient to whom you are assigned.

A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? Provide frequent mouth care. Maintain intravenous (IV) infusion at 100 mL/hr. Administer prochlorperazine (Compazine) via rectal suppository. Consult with dietitian on initial foods to offer patient. Control aversive odors or unpleasant visual stimulation that triggers nausea.

Consult with dietitian on initial foods to offer patient. Providing frequent mouth care and controlling outside stimulation that triggers nausea are independent interventions. Maintaining an IV infusion and administering the rectal suppository are dependent interventions.

The nurse reviews a patient's medical record and sees that tube feedings are to begin after a feeding tube is inserted. In recent past experiences the nurse has seen patients on the unit develop diarrhea from tube feedings. The nurse consults with the dietitian and physician to determine the initial rate that will be ordered for the feeding to lessen the chance of diarrhea. This is an example of what type of direct care measure? Preventive Controlling for an adverse reaction Consulting Counseling

Controlling for an adverse reaction Anticipating the need to start the feeding at a slower rate is an example of controlling for an adverse reaction, which in this case would be a harmful or unintended effect (diarrhea) of therapeutic intervention.

Which of the following statements characterizes criminal law? Criminal law applies to conduct that violates a person's rights. Criminal law involves an offense against an individual. Criminal law applies to conduct that is detrimental to society. The purpose of criminal law is to restitute the victim.

Criminal law applies to conduct that is detrimental to society. Criminal law is concerned with offenses against society in general. Civil law deals with personal rights. The purpose of criminal law is to punish the crime and to deter and prevent further crimes. Civil law's purpose is to make the aggrieved person whole again. Civil law applies to conduct that is detrimental to an individual.

A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: Data collection. Data clustering. Data interpretation. Making a diagnostic statement.

Data interpretation In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not included a related factor.

Which of the following factors puts an older adult at risk for physical, emotional, and financial abuse? Select all that apply. Decrease in strength and mobility Increase in independence Isolation Declining mental ability

Decrease in strength and mobility Declining mental ability

A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication? This patient is anxious about his pain after surgery; you need to review the information I gave him about how to use a patient-controlled analgesia (PCA) pump this evening. The nurse refers to the electronic care plan in the electronic health record (EHR) to review interventions for the patient's care. During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient. The nurse gives her patient a pain medication before report so there is likely to be no interruption during rounding.

During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient Creating a culture of blame does not support questioning, which is needed for good handoff communication. Talking about the patient's anxiety during handoff is patient centered and thus appropriate, referring to the EHR to review interventions ensures that essential information is included, and administering a pain medication before the report allows the nurse to be organized and uninterrupted during rounds.

Once a nurse is licensed, he or she can apply to another state for licensure by: Applying to take the NCLEX® examination in that state Interstate compact Endorsement Following the nurse practice act

Endorsement A nurse can apply for a license in another state by endorsement if all licensing criteria have been met for that state.The NCLEX® examination is a national licensure exam. It is not necessary to take it again. Interstate compact is a legal agreement among certain states that allows multistate practice of nursing as long as the nurse has a license in his or her home state. The Nurse Practice Act lists a nurse's scope of practice for the different licensure.

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as: Identifying the clinical sign instead of an etiology. Identifying a diagnosis based on prejudicial judgment. Identifying the diagnostic study rather than a problem caused by the diagnostic study. Identifying the medical diagnosis instead of the patient's response to the diagnosis.

Identifying the medical diagnosis instead of the patient's response to the diagnosis. In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.

A nurse is working in a neonatal intensive care unit (NICU) where a premature baby (26 weeks gestation) is facing respiratory disorders, numerous infections, and a brain hemorrhage. The parents want every measure to be taken to keep their baby alive, but several members of the health care team are advocating removal of life support. The nurse believes there are several ethical issues involved in this case. What step should the nurse take first when facing an ethical dilemma? Gather as much information as possible about the situation Identify the options available in this situation Act in a fair and equitable manner for all involved Evaluate the actions taken using ethical principles

Gather as much information as possible about the situation The nurse should clarify the ethical dilemma by gathering as much information as possible about the situation. This compares with the assessment phase of the nursing process and is the first step in the ethical decision making model. Most ethical dilemmas have multiple options, which should all be considered, but gathering additional data must be the first step. Making a decision and acting in a fair and equitable manner must take place, but gathering additional data is the first step. Evaluating the actions taken is the last step of the ethical decision making model.

Which of the following outcome statements for the goal, "Patient will achieve a gain of 10 lbs (4.5 kg) in body weight in a month" are worded incorrectly? (Select all that apply.) Patient will eat at least three fourths of each meal by 1 week. Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. Patient will eat foods with high-calorie content by 1 week. Give patient liquid supplements 3 times a day.

Give patient liquid supplements 3 times a day. Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. The statement 'Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week' is not singular. The statement 'Give patient liquid supplements 3 times a day' is an intervention.

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply.) Goal within reach of the patient The nurse's own competency in teaching about insulin The patient's cognitive function Availability of family members to assist

Goal within reach of the patient The patient's cognitive function goal must be realistic and one that the patient has cognitive and sociocultural potential to reach. The nurse's competency does not influence the patient's goal. However, it may mean that the nurse must consult with a diabetes educator or a more qualified nurse before beginning instruction.

The term for injury to a person or the person's property that gives rise to a basis for a legal action against the person who caused the damage is: Assault Harm Malpractice Negligence

Harm Assault is an intentional threat to cause bodily harm to another. It does not have to include actual bodily contact.Malpractice is the failure to meet a legal duty that results in harm to another. Negligence is the commission of an act or omission of an act that a reasonably prudent person would have done in a similar situation, leading to harm to another person.

A federal regulation that came into effect April 14, 2003 has impacted the health care field regarding privacy of a patient's health information. This regulation is the: Joint Commission on Accreditation of Healthcare Organizations Patient Self-Determination Act Patient's Bill of Rights Health Insurance Portability and Accountability Act

Health Insurance Portability and Accountability Act The Health Insurance Portability and Accountability Act of 1996 (HIPAA) came into effect on April 14, 2003 to safeguard a person's health information. It sets rules and limits on who can look at and receive health information. The Patient's Bill of Rights is the list of things that patients have the right to do or refuse to do. The Patient Self-Determination Act requires that institutions maintain written policies and procedures regarding advance directives, the right to accept or refuse treatment, and the right to participate fully in health care-related decisions. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is an organization that accredits health care facilities.

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? Value-belief pattern Cognitive-perceptual pattern Coping-stress-tolerance pattern Health perception-health management pattern

Health perception-health management pattern The nurse is attempting to learn about the patient's self-report of health practices, clinic appointments, and exercise plan designed to improve his health.

A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses the inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess? Health perception-health management pattern Value-belief pattern Cognitive-perceptual pattern Coping-stress tolerance pattern

Health perception-health management pattern The nurse assesses the patient's understanding of his therapy and level of adherence. She also assesses his health practices.

The nursing diagnosis readiness for enhanced communication is an example of a(n): Risk nursing diagnosis. Actual nursing diagnosis. Health promotion nursing diagnosis Wellness nursing diagnosis.

Health promotion nursing diagnosis A patient's readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient's motivation and desire to strengthen his health.

Which of the following are examples of collaborative problems? (Select all that apply.) Nausea Hemorrhage Wound infection Fear

Hemorrhage Wound infection Hemorrhage and wound infection are collaborative problems, actual or potential physiological complications. Nurses typically monitor for these to detect changes in a patient's status. 'Nausea' and 'fear' are both NANDA-I approved nursing diagnoses.

Using Maslow's hierarchy of needs, select the nursing diagnosis with the highest priority. Deficient knowledge Acute pain Risk for impaired skin integrity Imbalanced nutrition

Imbalanced nutrition The lack of nutrition falls in the base of Maslow's, therefore being of the highest importance. Whenever there is risk, it is not the main priority in the plan of care, but the result of another problem. Pain is a result of another problem and falls in Maslow's level of safety and security. Knowledge deficit is generally a result of another problem and falls in Maslow's level of safety and security

A patient is admitted to the hospital with a sacral wound that has a foul odor, purulent drainage, and necrotic tissue in the center. It measures 4 cm in circumference by 2 cm deep. Select the most appropriate nursing diagnosis. Risk for infection Impaired skin integrity Chronic pain Impaired peripheral circulation

Impaired skin integrity The collected data all show that there is an impaired skin integrity.The data show that an infection is already present and so the diagnosis needs to be actual and not risk for. More data would need to be collected to know if the patient has pain. Impaired peripheral circulation -More assessment data would need to be collected, so it is not the most appropriate at this time.

Your patient has returned from surgery and has a history of smoking. The physician has orders for the use of incentive spirometry (IS) every 2 hours. The patient asks why he has to do IS so often. You teach your patient about the importance of breathing deeply, to clear any secretions and its prevention of pneumonia. This teaching is an example of: A nursing diagnosis An outcome statement Implementation of a nursing intervention The nursing process

Implementation of a nursing intervention Correct Teaching is the implementation of a nursing intervention or physician order. A nursing diagnosis is an identified problem. An outcome statement is what you want to see your patient do or how they improve. The nursing process is a 6-step process in which teaching is only one step.

Setting a time frame for outcomes of care serves which of the following purposes? Indicates which outcome has priority Indicates the time it takes to complete an intervention Indicates how long a nurse is scheduled to care for a patient Indicates when the patient is expected to respond in the desired manner

Indicates when the patient is expected to respond in the desired manner The time frame indicates when you expect a response to your nursing interventions. Time frames help to organize priorities but do not indicate which problem is most important. Time frames for outcomes are not used to gauge the time it takes to complete interventions, and they are unrelated to a nurse's work schedule.

The nurse is planning care of a patient with difficulty breathing due to a medical diagnosis of COPD. Which of the following should the nurse determine is the priority nursing diagnosis? Knowledge deficit regarding use of inhaler Sleep pattern disturbance Spiritual distress Ineffective airway clearance

Ineffective airway clearance Airway clearance is a high priority physiological need and should take priority over non-physiological, basic needs. Knowledge deficit, sleep pattern disturbance, and spiritual distress are all important needs, but physiological needs should be the priority of care.

The nurse is caring for a patient who is scheduled for surgery. Prior to going to surgery the nurse would make sure that the patient has been fully informed about the procedure to be done. What would the patient sign to acknowledge that he or she is making an intelligent decision? Patient's Bill of Rights Accountability statement Informed consent doctrine Confidentiality statement

Informed consent doctrine An informed consent doctrine is a person's agreement to allow a particular treatment based on full disclosure of the facts needed to make an intelligent decision. The patient's Bill of Rights is a list of rights of the patient that includes the right of an informed consent. Accountability is the responsibility of the nurse as part of the care to be given to the patient. Confidentiality is the responsibility of the nurse as part of the care to be given to the patient.

A nurse reports a medication error and monitors the patient, who suffers no ill effects. Which element is lacking to prove nursing malpractice? Duty of care Breach of duty Injury Standard of care

Injury Since there is no injury, then malpractice cannot be proven. Breach of duty, duty of care, and standard of care are not relevant elements in this case.

The nurse is providing patient education for a patient newly diagnosed with diabetes mellitus. When the nurse teaches the patient how to administer insulin, the nurse is demonstrating which phase of the nursing process? Diagnosis Planning Evaluation Interventions

Interventions A nurse providing patient education on self-administration of insulin is demonstrating the intervention phase of the nursing process. Teaching patients is not an example of diagnosis, planning, or evaluation.

A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing? So you've had an upset stomach and began vomiting—correct? Have you taken anything for your stomach? Is anything else bothering you? Have you taken any medication for your vomiting?

Is anything else bothering you? A probing question encourages a full description without trying to control the direction of the patient's story. It requires further open-ended statements. Confirming an upset stomach and vomiting is an example of summarizing findings. The questions about medications taken are examples of closed-ended questions that control the patient's response and do not ensure a full objective view from the patient.

On a medical unit, several patients are being treated for Hepatitis B infection. One of the patients contracted Hepatitis B through using infected needles associated with heroin use. Another of the patients contracted Hepatitis B through a blood transfusion following a car accident. Several of the employees on the unit treat the patient who used heroin rudely and delay their attention to the patient's requests. The nurse intervenes and reminds the staff to use which ethical principle? Justice Nonmaleficence Beneficence Autonomy

Justice Justice describes providing patients with the same diagnosis and health care needs the same care. By delaying attention to the patient's requests and treating the patient rudely, the staff is not using the principle of justice. Nonmaleficence is the duty to do no harm. Beneficence is frequently described as "the doing of good." Autonomy means that individuals have the right to determine their own actions and the freedom to make their own decisions.

When caring for patients, the nurse knows that part of the ethical principles include all patients having the same right to nursing interventions. This principle is: Autonomy Nonmaleficence Justice Beneficence

Justice Justice in nursing means that nurses must allocate time among all the assigned patients to meet their needs.Autonomy refers to personal freedom of choice, a right to be independent and make decisions freely. Nonmaleficence means to do no harm.Beneficence means doing what is good.

A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply.) Maintain a neutral facial expression Lean forward when interacting with the patient Acknowledge the patient's answers through head nodding Limit direct eye contact

Lean forward when interacting with the patient Acknowledge the patient's answers through head nodding Leaning forward shows that the nurse is aware and attending to what the patient is saying. The use of head nodding regulates the interaction and makes it easier for the patient to know the nurse's responses to his comments. A neutral expression does not express warmth or immediacy, which is needed to establish a positive relationship. Good eye contact communicates the nurse's interest in what the patient has to say.

A recent graduate of a nursing program has accepted a position in a long term care unit. The nurse can use which strategy to reduce the risk of malpractice suits? Carry malpractice insurance Request supervision for all care Not sign his or her name in patient records Maintain good relationships with patients and families

Maintain good relationships with patients and families Maintaining good relationships with patients and families does reduce the risk of malpractice suits. Carrying malpractice insurance does not reduce the risk of a malpractice suit. Requesting supervision for all care provided is not feasible in many situations and does not reduce the risk of malpractice suits. Not signing patient records can actually increase the risk of lawsuits, as failure to document is considered a category of negligence that results in malpractice lawsuits.

The LPN/LVN knows that building the nurse-patient relationship is important in providing patient care, and a legal relationship is being formed. If there is a breach in this relationship and harm to the patient has occurred, which legal action can the nurse be charged with? Assault Negligence Slander Malpractice

Malpractice Malpractice in the failure to meet a legal duty that results in harm to another. Slander in malicious or untrue spoken words about another person or property.Negligence is the commission or omission of an act that a reasonably prudent person would have done in a similar situation that leads to harm to another person.Assault is an intentional threat to cause bodily harm to another.

A nurse is providing patient teaching for a patient undergoing chemotherapy. The nurse is explaining that the chemotherapy will cause some unpleasant side effects, such as nausea and hair loss. In this situation, the nurse is using which ethical principle? Beneficence Nonmaleficence Autonomy Justice

Nonmaleficence Nonmaleficence involves the duty to do no harm. Although the patient will experience nausea and hair loss (harm), the treatment will eventually produce good for the patient. Beneficence is frequently defined as the "doing of good." Autonomy means that individuals have the right to determine their own actions and the freedom to make their own decisions. Justice means that the same care is provided to patients with similar diseases and health care needs.

Following the gathering of subjective and objective data, performing a health history and a physical assessment, the nurse sets up a plan of care. The first step is to identify the problem with a(n): Medical diagnosis Nursing intervention Nursing diagnosis Evaluation

Nursing diagnosis The nursing diagnosis is the title or label given to an identified problem and is the first step is a patient's plan of care.A medical diagnosis is the problem identified by the physician upon 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.

"Ambulate the patient three times a day at 0900, 1400, 1900 as tolerated" is an example of: Nursing order Nursing diagnosis Patient goal Evaluation

Nursing order This statement is an example of an intervention that has been made more specific to the patient, which is a nursing order.A nursing diagnosis is a NANDA-approved statement that identifies a specific problem. A patient goal is a statement that includes what the patient needs to do to make changes in the problem. Evaluation is the review of the plan of care to see what revisions are necessary to the plan of care.

n experienced nurse would best demonstrate collegiality with a novice nurse by which of the following behaviors? Allowing the novice plenty of independence to "get his feet wet" Overlooking mistakes to avoid embarrassing the novice nurse Asking a nursing instructor on the unit to take students elsewhere so the novice nurse can complete assigned tasks. Offering to serve as a mentor to the novice with mutually agreed on goals.

Offering to serve as a mentor to the novice with mutually agreed on goals. A nurse would best demonstrate collegiality with a novice nurse by offering to serve as a mentor to the novice. Allowing the novice to "get his feet wet" does not display behavior that supports another nurse. Overlooking mistakes does not serve as a positive role model. Asking students to leave does not demonstrate welcoming behavior.

The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? (Select all that apply.) Daughter's concern of mother's risk for injury Pacing Patient getting lost easily Daughter working part time Getting up frequently

Pacing Patient getting lost easily Getting up frequently Pacing, getting lost, and hyperactivity are a cluster of defining characteristics that point to the diagnostic label of wandering

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which of the following patient care goals are long term? Patient will explain relationship of insulin to blood glucose control. Patient will self-administer insulin. Patient will achieve glucose control. Patient will describe steps for preparing insulin in a syringe.

Patient will achieve glucose control. It will take time for the patient who is medically unstable to achieve glucose control. Explaining the relationship of insulin to blood glucose control and self-administering insulin are short term goals and should be met before discharge. Describing steps for preparing insulin in a syringe is not a goal but an outcome statement for the goal that the patient will self-administer insulin.

A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply.) Patient will be turned every 2 hours within 24 hours. Patient will have normal bowel function within 72 hours. Patient's skin will remain intact through discharge. Patient's skin condition will improve by discharge.

Patient will have normal bowel function within 72 hours. Patient's skin will remain intact through discharge. The skin remaining intact is an appropriate goal for the patient's at-risk diagnosis. A return of normal bowel functioning is also appropriate since it indicates removal of a risk factor. Turning the patient is an intervention; skin condition improving by discharge is a poorly written goal that is not measurable.

The nurse writes an expected-outcome statement in measurable terms. An example is: Patient will be pain free. Patient will have less pain. Patient will take pain medication every 4 hours. Patient will report pain acuity less than 4 on a scale of 0 to 10.

Patient will report pain acuity less than 4 on a scale of 0 to 10. Answer 4 is measurable because it is the only outcome statement that allows the nurse to obtain an actual measure of the patient's pain. The patient being pain free is a goal; the patient having less pain is written vaguely, and the patient taking pain medication every 4 hours is an intervention.

During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply.) Family report Chest x-ray film Physical examination with auscultation of the lungs Medical record summary of x-ray film findings

Physical examination with auscultation of the lungs Medical record summary of x-ray film findings The family cannot provide information to reveal that the cough is a lung problem. A chest x-ray film is not a nursing assessment; if a previous chest x-ray film had been performed, the nurse could review that report to confirm a lung problem.

A nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion the nurse checks the patient's medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventive intervention? Tertiary Direct care Primary Secondary

Primary An immunization is an example of a primary prevention aimed at health promotion.

A nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment? Agenda setting Problem-focused Objective Use of a structured database format

Problem-focused The nurse saw the inflammation and gathered additional information to determine if a problem existed with the IV site. The data were not all objective; the patient's report of tenderness is subjective. Setting an agenda is an interview technique. The nurse was not using a structured format for her assessment.

The nurse enters a patient's room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? Meeting the patient's expressed wishes Indirect care measure Protecting a patient from injury Staying organized when implementing a procedure

Protecting a patient from injury A common method for administering physical care techniques appropriately includes protecting you and your patients from injury, which involves safe patient handling. Transferring a patient is a direct care measure. Organization is an aspect of physical care but not an example of this nurse's action. Although meeting patient needs is important, it is not a physical care technique.

When a nurse properly positions a patient and administers an enema solution at the correct rate for the patient's tolerance, this is an example of what type of implementation skill? Interpersonal Cognitive Collaborative Psychomotor

Psychomotor Psychomotor skills require the integration of cognitive and motor activities to ensure safe intervention.

A patient signals the nurse by turning on the call light. The nurse 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. Which of the following does the nurse perform first? Reconnect the drainage tubing Inspect the condition of the IV dressing Improve the patient's comfort and turn onto her side. Obtain the next IV fluid bag from the medication room

Reconnect the drainage tubing The priority is to reconnect the drainage tube. This can be done quickly and prevents fluid loss and reduces risk of infection spreading up into the tube. Next the nurse turns the patient for comfort. With 100 mL of fluid remaining, the nurse has time to perform these tasks. The nurse can inspect the IV dressing last, after going to obtain the next IV fluid bag.

During the implementation step of the nursing process, a nurse reviews and revises the nursing plan of care. Place the following steps of review and revision in the correct order: Review the care plan. Decide if the nursing interventions remain appropriate. Reassess the patient. Compare assessment findings to validate existing nursing diagnoses.

Review the care plan. Decide if the nursing interventions remain appropriate. After reassessing a patient, the nurse reviews the care plan and compares assessment data to validate the nursing diagnoses and determine whether the nursing interventions remain the most appropriate for the clinical situation. If the patient's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, the nurse modifies the nursing care plan.

A nurse is starting on the evening shift and is assigned to care for a patient with a diagnosis of impaired skin integrity related to pressure and moisture on the skin. The patient is 72 years old and had a stroke. The patient weighs 250 pounds and is difficult to turn. As the nurse makes decisions about how to implement skin care for the patient, which of the following actions does the nurse implement? (Select all that apply.) Review the set of all possible nursing interventions for the patient's problem Review all possible consequences associated with each possible nursing action Consider own level of competency Determine the probability of all possible consequences

Review the set of all possible nursing interventions for the patient's problem Review all possible consequences associated with each possible nursing action When making decisions about implementation, reviewing all possible interventions and consequences and determining the probability of consequences are necessary steps. The nurse is responsible for having the necessary knowledge and clinical competency to perform an intervention, but this is not part of the decision making involved.

In which of the following examples is a nurse applying critical thinking attitudes when preparing to insert an intravenous (IV) catheter? (Select all that apply.) Following the procedural guideline for IV insertion Seeking necessary knowledge about the steps of the procedure from a more experienced nurse Showing confidence in performing the correct IV insertion technique Being sure that the IV dressing covers the IV site completely

Seeking necessary knowledge about the steps of the procedure from a more experienced nurse Showing confidence in performing the correct IV insertion technique Seeking necessary knowledge about the steps of the procedure shows humility. The nurse recognizes that she needs clarification from a senior colleague. Another example of a critical thinking attitude is confidence. In this case confidently inserting an IV line allows the nurse to convey expertise and a sense of calm, leading the patient to trust the nurse. Following policy and procedure is an example of following standards of care, not of a critical thinking attitude. Making sure that the dressing is covered is a step in following good standards of IV care but is not a critical thinking attitude.

Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure? (Select all that apply.) Seeks necessary knowledge Reassesses the patient's condition Collects all necessary equipment Delegates the procedure to a more experienced staff member Considers all possible consequences of the procedure

Seeks necessary knowledge Considers all possible consequences of the procedure You require additional knowledge and skills in situations in which you are less experienced. When you are asked to administer a new procedure with which you are unfamiliar, follow the three choices: seek necessary knowledge, collect necessary equipment, and consider all possible consequences of the procedure. Collecting necessary equipment and considering potential consequences is needed for any procedure.

A patient outcome statement or goal is (select all that apply): Specific to the patient Given a time frame for completion Indicative of an increase of the problem Realistic for the patient

Specific to the patient Given a time frame for completion Realistic for the patient

A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, "Why do we have standing orders for cases when patients develop life-threatening arrhythmias? Is not each patient's situation unique?" What is the nurse's best answer? Standing orders are used to meet our physician's preferences. Standing orders ensure that we are familiar with evidence-based guidelines for care of arrhythmias. Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation. Standing orders minimize the documentation we have to provide.

Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation. Standing orders are preprinted documents containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. They are common in critical care settings and other specialized practice settings in which patients' needs change rapidly and require immediate attention.

As part of their right to refuse treatment, patients may prepare advance directives specifying what life-saving treatments they do or do not wish to receive. When determining the legality of an advance directive, the nurse should know the applicable _______ laws. Federal State County Local

State State laws vary on the legalities of the various forms of advance directives, so the nurse needs to know the applicable state laws.

LPN/LVNs need to know what they can and cannot do within their scope of practice. They would need to refer to: Interstate compact ANA The Nurse Practice Act of their licensing state Their employing institution

The Nurse Practice Act of their licensing state The state in which the nurse receives licensing has adopted a Nurse Practice Act that defines the scope of nursing practice for the LPN/LVN within that state. The interstate compact in a legal agreement that allows multistate practice of nursing.ANA is involved in developing standards of care for nursing practice. The employing institution may limit further the scope of practice for an LPN/LVN, but it is for that institution only.

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which of the following describe the nurse's actions? (Select all that apply.) The application of the skin barrier is a dependent care measure. The call to the ostomy and wound care specialist is an indirect care measure. The cleansing of the skin is a direct care measure. The application of the skin barrier is a direct care measure.

The call to the ostomy and wound care specialist is an indirect care measure The cleansing of the skin is a direct care measure. The call to the ostomy and wound care specialist is an indirect care measure involving collaborative care. Cleansing the skin is an independent direct care measure. Applying the skin barrier is an independent nursing measure involving direct care.

Which of the following are examples of data validation? (Select all that apply.) The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record. The nurse asks the patient if he is having pain and then asks the patient to rate the severity. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement. The nurse asks the patient to describe a symptom by saying, "Go on."

The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement. Validation involves comparing data with another source. By asking the patient about pain and then having it rated the nurse collects two assessment findings. The nurse asking an open-ended question about the patient's understanding of the booklet is not data validation. Telling the patient to go on; is back channeling.

In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.) The nurse who listens to lung sounds after a patient reports "difficulty breathing" The nurse who considers conflicting cues in deciding which diagnostic label to choose The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema The nurse who identifies a diagnosis on the basis of a single defining characteristic

The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema The nurse who identifies a diagnosis on the basis of a single defining characteristic When the nurse assesses edema without knowing how to assess the severity, the nurse fails to validate her assessment findings of edema, either by using a scale to measure the severity or by asking a colleague to validate her findings. In identifying a diagnosis on the basis of a single defining characteristic, the nurse prematurely closes clustering, which can lead to an inaccurate diagnosis. By listening to lung sounds after the patient reports 'difficulty breathing' the nurse validates findings to make an accurate diagnosis. The nurse interprets cue clusters to make an accurate diagnosis when considering conflicting cues to make a diagnosis.

A nurse manager is conducting an employee evaluation for a new employee. Which employee behavior best indicates that the nurse is providing patient-centered care? The nurse shares his or her own personal problems in order to obtain the patient's trust and to show empathy with the family. The nurse avoids raising the patient's anxiety by chatting about pleasant topics before unpleasant procedures. The nurse clarifies patients' reasons for refusing medications without becoming defensive. The nurse avoids upsetting patients by not bringing up health care issues that might upset the patient.

The nurse clarifies patients' reasons for refusing medications without becoming defensive. Providing patient-centered care involves clarifying patients' reasons for refusing medications. Refraining from discussing own concerns demonstrates a patient-centered approach. The nurse displays patient-centered care by attempting to talk the patient through anxiety-laden procedures. Avoiding discussing health issues does not display a patient- centered approach.

A charge nurse is evaluating the performance of a staff nurse. Which activity best demonstrates expert thinking, rather than novice thinking? The nurse focuses on own actions. The nurse follows clear-cut rules. The nurse considers options before acting. The nurse relies on step-by-step procedures.

The nurse considers options before acting. A nurse who assesses and considers different options for intervening before acting is demonstrating expert thinking. Novice thinking is characterized by focusing on one's own actions, following clear-cut rules, and relying on step-by-step procedures.

The nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest? The nurse is making an accurate clinical inference. The nurse has gathered cues to identify a potential problem area. The nurse has allowed stereotyping to influence her assessment. The nurse wants to validate her information with the other nurse.

The nurse has allowed stereotyping to influence her assessment. The nurse is applying a stereotype about patients with back pain. An accurate clinical inference would not include the nurse's opinion. The cues suggest that the patient has acute pain, which the nurse is rejecting. Validation would involve having another nurse also assess the patient for pain.

The patient has a central venous line. The registered nurse (RN) delegates changing the sterile dressing over the line to a nursing assistant. The nursing assistant does not understand sterile technique and contaminates the dressing. An infection develops in the patient. The nurse manager discusses the action of the RN. Which statement is correct regarding the nurse's action? The nursing assistant is guilty of malpractice. The nurse is responsible for the acts delegated. The hospital cannot be held responsible for the act of its employees. No harm came to the patient, so a malpractice suit cannot be claimed.

The nurse is responsible for the acts delegated. The registered nurse is responsible for delegating appropriately. It is not appropriate to delegate a skill requiring sterile technique and assessment of a central line site to a nursing assistant. It is not within the nursing assistant's scope of practice to perform central line dressing changes. The hospital is responsible for the acts of its employees under the concept of respondeat superior. Harm was caused by this act, since the patient did develop an infection, so a malpractice suit can be claimed.

The registered nurse, employed by the risk management department of a hospital is giving an inservice class on social media to nursing employees. Which one of these statements should be included in this class? Posts are private and accessible only to the intended recipient. Once content has been deleted, it is no longer accessible. No harm is done if patient information is disclosed only to the intended recipient. The nurse should not refer to a patient, even by nickname or room number.

The nurse should not refer to a patient, even by nickname or room number. The nurse should never refer to a patient on social media, even by nickname or room number. Social media posts are not considered private and are not always accessible only to the intended recipient. Even deleted content is accessible at times on social media. Disclosing any patient information is a harmful act, even if it is disclosed only to the intended recipient.

A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital versus one for home care? The goals of care will always be more long term. The patient and family need to be able to independently provide most of the health care. The patient's goals need to be mutually set with family members who will care for him or her. The expected outcomes need to address what can be influenced by interventions.

The patient and family need to be able to independently provide most of the health care. A community-based health care setting such as home health must work with patients and their families to set goals and outcomes that ultimately lead to a plan that allows them to provide the majority of care themselves. Goals of care will not always be more long term; goals will be short term and long term, depending on the patient's condition. Mutually setting goals with caregiving family members is true for any health care setting. The statement "The expected outcomes need to address what can be influenced by interventions" is incorrect; the outcomes allow you to direct your evaluation of care.

A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply.) The family comes to visit the patient. The patient expresses concern about pain control. The patient's vital signs change, showing a drop in blood pressure. The charge nurse approaches the nurse and requests a report at end of shift.

The patient expresses concern about pain control. The patient's vital signs change, showing a drop in blood pressure. Pain control is a priority, because it is severe and affects the patient's ability to rest after surgery and be able to perform necessary activities. A change in vital signs is a priority, and the change could be related to the patient's pain. However, because of the nature of surgery, the nurse has to reassess for any bleeding, which lowers blood pressure. Attending to the family is important to lend the patient needed support, but it is not the initial priority. Finally the nurse must attend to urgent patient needs before completing a report.

The nurse is documenting several aspects of an assessment conducted on a patient newly admitted to the hospital with a suspected myocardial infarction. Which of the following is considered objective data? The patient states, "I feel like an elephant is standing on my chest." The patient is diaphoretic, pale, hypotensive, and tachycardic The patient states, "This is the worst pain I have had in my life." The patient states, "I have pain under the breastbone in my chest."

The patient is diaphoretic, pale, hypotensive, and tachycardic Objective data is the type of data that the nurse will collect through observation of the patient. It is measurable, and often called signs. The patient statements of a feeling of an elephant standing on the chest, severe pain, and pain under the breastbone are all examples of subjective data.

The nurse is planning care for an 8-year-old patient who had undergone a tonsillectomy yesterday and is having difficulty increasing fluid intake postoperatively due to incisional pain. Which of the following is an appropriate patient goal? The patient will consume 1000 ml within 24 hours. Provide the patient with small sips of favorite liquids. Encourage the patient to take prescribed pain medications. Apply an ice collar to the patient's throat if desired.

The patient will consume 1000 ml within 24 hours. A goal is a statement of what is to be accomplished. It should be stated in terms of what the patient will do rather than what the nurse will do. The statement "the patient will consume 1000 ml of fluid within 24 hours" is a goal. The statements regarding providing sips of liquids, administering pain medications and ice collars are nursing interventions, not goals.

A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply.) The skin around the wound is tender to touch. Fluid intake for 8 hours is 800 mL. Patient has a heart rate of 78 and regular. Patient has drainage from surgical wound. Body temperature is 101° F (38.3° C). Patient asks, "I'm worried that I won't return to work when I planned."

The skin around the wound is tender to touch. Patient has drainage from surgical wound. Body temperature is 101° F (38.3° C). These form a pattern of a problem with wound healing. Fluid intake of 800 mL in 8 hours and having a heart rate of 78 are normal findings. The patient indicating some worry about not returning to work when planned may suggest a problem, but more cues are needed to see a pattern that would allow the nurse to clearly identify the problem.

A nurse is on duty in the emergency room when the nurse is notified that a school bus has been struck by a train. Immediately the nurse reports to the triage area and begins the task of determining the severity of injuries, so that the most critical patients receive care first. Which ethical theory is the nurse putting into action? Utilitarianism Act deontology Rule deontology Virtue ethics

Utilitarianism Utilitarian ethics states that "what makes an action right or wrong is its utility, with useful actions bringing about the greatest good for the greatest number of people." By triaging the patients according to the severity of the injury, the nurse will be able to save the lives of more patients, thus doing the greatest good for the greatest number of people. Act deontologists determine the right thing to do by gathering all the facts and then making a decision. Rule deontologists emphasize that principles guide our actions. Virtue ethics are tendencies to act, feel, and judge that develop through appropriate training but come from natural tendencies.

Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply.) Acute pain related to lumbar disk repair Sleep deprivation related to difficulty falling asleep Constipation related to inadequate intake of liquids Potential nausea related to nasogastric tube insertion

cute pain related to lumbar disk repair Sleep deprivation related to difficulty falling asleep Potential nausea related to nasogastric tube insertion Acute pain related to lumbar disk repair uses a medical diagnosis as a related factor. Sleep deprivation related to difficulty falling asleep uses a clinical sign rather than a treatable etiology such as 'excess noise in environment.' Potential nausea related to nasogastric tube insertion uses a diagnostic study as the etiology. None of the etiologies can be managed or treated by nursing intervention.

A nurse identifies several interventions to resolve the patient's nursing diagnosis of impaired skin integrity. Which of the following are written in error? (Select all that apply.) Turn the patient regularly from side to back to side. Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence. Apply a pressure-relief device to bed. Apply transparent dressing to sacral pressure ulcer.

turn the patient regularly from side to back to side. Apply a pressure-relief device to bed. The statements 'Turn the patient regularly from side to back to side' and 'Apply a pressure-relief device to bed' do not provide specific guidelines for the frequency or type of intervention. The other two options identify specific intervention methods.