nursing 110 test5

1. The nurse practioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? a. Comprehensive b. Initial c. Time-lapsed d. Quick priority

1. : quick priority assessments (QPAs) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.

1. Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply a. Closely assess the patient before, during, and after the procedure b. Hyperoxygenate the patient before and after suctioning c. Limit the application of suction to 20-30 seconds d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus. Nerve e. Use an appropriate suction pressure (80-150 mm Hg) f. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube

1. A, B, D, and E: close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80-150 mm Hg) will help prevent atelectasis related to high use of negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis.

1. The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply a. A patient tells the nurse that she is feeling nauseous b. A patient's ankles are swollen c. A patient tells the nurse that she is nervous about her test results d. A patient complains that the skin on her arm is tingling e. A patient rates his pain as a 7 on a scale of 1 to 10 f. A patient vomits after eating supper

1. A, C, D, and E: subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (101 F), edema, and vomiting.

1. A nurse researcher keeps current on the trends to watch in health care delivery. What trends are likely included? Select all that apply a. Globalization of the economy and society b. Slowdown in technology development c. Decreasing diversity d. Increasing complexity e. Changing demographics f. Shortages of key health care professionals and educators

1. A, D, E, and F: trends to watch in health care delivery include globalization of the economy and society, increasing complexity of patient care, changing demographics, shortages of key health care professionals and educator , technology explosion, and increasing diversity

1. Nurses provide care to patients as collaborative members of the health care team. Which roles may be performed by the advanced practice registered nurse? Select all that apply a. Primary care provider b. Hospitalist c. Physical therapist d. Anesthetist e. Midwife f. Pharmacist

1. A, D, and E: the advanced practice registered nurse (APRN) is a registered nurse educated at the master's or post-master's level in a specific role and for a specific population. Whether they are nurse practioner's, clinical nurse specialist, nurse anesthetist, or nurse midwives. APRNs play a pivotal role in the future of health care APRNs are often primary care providers and are the forefront of providing preventative care to the public. Hospitalist are health care providers who provide care to patients when they visit the emergency department or are admitted to the hospital. A physical therapist completes a specific training program to learn to help patients restore function or to prevent further disability in a patient after an injury or illness. A pharmacist, prepared at the doctoral level is licensed to formulate and dispense medications.

1. A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply a. The nurse carefully removes the bandages from a burn victim's arm b. The nurse assesses a patient to check nutritional status c. The nurse formulates a nursing diagnosis for a patient with epilepsy d. The nurse turns a patient in bed every 2 hours to prevent pressure injuries e. The nurse checks a patient's insurance coverage at the initial interview f. The nurse checks for community resource for a patient with dementia

1. A, D, and F: during the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.

1. The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preclampsia. The patient ask the nurse: "why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply a. "the nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths" b. "it's hospital policy. I know it must be tiresome, but I will try to make this quick." c. "I'm a student nurse and I need to develop the skill of assessing your health status and need for nursing care." d. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate" e. "we need to check your health status and see what kind of nursing care you may need." f. "we need to see if you require a referral to a physician or other health care professional."

1. A, E, and F: Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgement about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and wellbeing, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.

1. A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply a. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. b. The nurse uses a binary decision tree for stepwise assessment and intervention c. The nurse is able to measure the cause and effect relationship between pathway and patient outcomes d. The nurse uses broad, research based practice recommendations that may or may not have been tested in clinical practice e. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research f. The nurse uses a decision tree that provides intense specificity and no provider flexibility

1. A, and C: a critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order process after a practice standard has been validated through analytical research

1. The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. a. The nurse uses critical thinking skills to plan care for a patient b. The nurse correctly administers IV saline to a patient who is dehydrated c. The nurse assists a patient to fill out an informed consent form d. The nurse learns the correct dosages for patient pain medications e. The nurse comforts a mother whose baby was born with down syndrome f. The nurse uses the proper procedure to catheterize a female patient

1. A, and D: using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent for is a legal/ethical issue, and comforting a patient is an interpersonal skill.

1. A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: 1. Disturbed body image 2. Ineffective airway 3. Spiritual distress 4. Impaired social interaction Which answer choice below lists the problem based on Maslow's model a. 2, 4, 1, 3 b. 3, 1, 4, 2 c. 2, 4, 3, 1 d. 3, 2, 4, 1

1. A: 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs to prioritized according to Maslow's hierarchy: 1) physiologic needs, 2) safety needs, 3) love and belonging needs, 4) self-esteem needs, and 5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of self-esteem need, and #3 is an example of self-actualization need

1. When the initial nursing assessment revealed that a patient had not had a bowel movement in 2 days, the student nurse wrote the diagnostic label "constipation." What would be the instructor's best response to this student's diagnosis? a. "was the diagnosis derived from a cluster of significant data or a single clue." b. "this early diagnosis will help us manage the problem before it becomes more acute." c. "have you determined if this is an actual problem or a possible diagnosis?" d. "this condition is a medical problem that should not have a nursing diagnosis."

1. A: Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. A data cluster is a grouping of patient data or cues that point to the existence of a patient health problem. There may be a reason for the lack of a bowel movement for 2 days, or it might be this person's normal pattern.

1. A nurse is assessing a patient who is diagnoses with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: a. Clinical judgement b. Clinical reasoning c. Critical thinking d. Blended competencies

1. A: although all the options refer to the skills used by nurses in practice, the best choice is clinical judgement as it refers to the result or outcome of critical thinking or clinical reasoning-in this case, the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical and legal skills combined with the willingness to use them creatively and critically when working with patients.

1. An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? a. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. b. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. c. The emphasis on logical, scientific, evidence based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking. d. It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive critical thinkers.

1. A: beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer B is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.

1. A nurse is working in a primary care facility prepares insurance forms in which the provider is given a fixed amount per enrollee of the health plan. What is the term for this type of reimbursement? a. Capitation b. Prospective payment system c. Bundled payment d. Rate setting

1. A: capitation plans give providers a fixed amount per enrollee in the health plan in an effort to build a payment plan that consist of the best standards of care at the lowest cost. The prospective payment system groups inpatient hospital services for medicare patients into DRGs. With bundled payments, providers receive a fixed sum of money to provide a range of services. Rate setting means that the government could set targets or caps for spending on health care services

1. A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome? a. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body b. By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself c. Following physical therapy, patient will begin to gradually participate in walking/running events d. By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events

1. A: clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activites. Quality of life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes

1. A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? a. Dyspnea b. Hypotension c. Decreased respiratory rate d. Decreased pulse rate

1. A: if a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which as inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with small pulse pressure, increased respiratory and pulse rates, pallor and cyanosis

1. A nurse caring for patients in a primary care setting submits paperwork for reimbursement from managed care plans for services performed. Which purpose best describes managed care as a framework for health care? a. A design to control the cost of care while maintaining the quality of care b. Care coordination to maximize positive outcomes to contain costs c. The delivery of services from initial contact through ongoing care d. Based on philosophy of ensuring death in comfort and dignity

1. A: managed care is a way of providing care designed to control costs while maintaining the quality of care

1. A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? a. Perform the focused assessment as this is an independent nurse-initiated intervention b. Request an order from Jill's physician since this is a physician-initiated intervention c. Request an order from Jill's physician since this is a collaborative intervention d. Request an order from the nutritionist since this is a collaborative intervention

1. A: performing a focused assessment is an independent nurse-initiated intervention: thus the nurse does not need an order from the physician or nutritionist.

1. A caregiver asks a nurse to explain respite care. How would the nurse respond? a. "respite care is a service that allows time away for caregivers" b. "respite care is a special service for the terminally ill and their family" c. "respite care is direct care provided to people in a long term care facility" d. "respite care provides living units for people without regular shelter"

1. A: respite care is provided to enable a primary caregiver time away from the day-to-day responsibilities of homebound patients.

1. A nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing in a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What would be the student's best response? a. Tell the RN that he or she lacks the technical competencies to change the dressing independently b. Assemble the equipment for the procedure and follow the steps in the procedure manuel c. Ask another student nurse to work collaboratively with him or her to change the dressing d. Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses

1. A: student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the care plan. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.

1. A nurse is using the SOAP format to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? a. A patient problem list b. Narrative notes describing the patient's condition c. Overall trends in the patient status d. Planned interventions and patient outcomes

1. A: the SOAP format (Subjective data, Objective data, Assessment, Plan) is used to organize entries in the progress notes of a POMR. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Overall trends in patient status can be seen immediately when using CBE, no tSOAP charting. Planned interventions and patient-expected outcomes are the focus of the case management model.

1. What action does the nurse perform to follow safe technique when using portable oxygen cylinder? a. Check the amount of oxygen in the cylinder before using it b. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi c. Placing the oxygen cylinder on the stretcher next to the patient d. Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight

1. A: the cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight.

1. A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? a. "you made an inference that she is fine because she has no complaints. How did you validate this?" b. "she probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." c. "sometimes everyone gets lucky. Why don't you try to help another patient." d. "maybe you should reassess the patient. She has to have a problem-why else would she be here."

1. A: the instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.

1. A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? a. Remove the catheter b. Notify the primary care provider c. Check that the airway is the appropriate size for the patient d. Place the patient on his or her back

1. A: when a patient vomits upon suctioning of an oropharyngeal airway, the nurse should remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, the nurse should change the catheter, because it is probably contaminated. The nurse should also turn the patient to the side and elevate the head of the bed to prevent aspiration.

1. When may a health institution release a PHI for purposed other than treatment, payment, and routine health care operations, without the patient's signed authorization? Select all that apply a. News media are preparing a report on the condition of a patient who is a public figure b. Data are needed for the tracking and notification of disease outbreaks c. Protected health information is needed by a coroner d. Child abuse and neglect are suspected e. Protected health information is needed to facilitate organ donation f. The sister of a patient with Alzheimer's disease wants to help provide care

1. B, C, D, and E: according to HIPAA, a health institution is not required to obtain written patient authorization to release PHI for tracking disease outbreaks, infection control, statistics related to dangerous problems with drugs or medical equipment, investigation and prosecution of a crime, identification of victims of crimes or disaster, reporting incidents of child abuse, neglect or domestic violence, medical records released according to a valid subpoena, PHI needed by coroners, medical examiners, and funeral directors, PHI provided to law enforcement in the case of a death from a potential crime, or facilitating organ donations. Under no circumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease

1. An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply a. Performing the initial patient assessments b. Making patients beds c. Giving patients bed baths d. Administering patient medications e. Ambulating patients f. Assisting patients with meals

1. B, C, E, and F: performing the initial patient assessment and administering medications are the responsibility of the RN. In most cases, patient hygiene, bed- making, ambulating patients, and helping feed patients can be delegated to a UAP

1. A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? a. The nurse formulates nursing diagnoses b. The nurse identifies expected patient outcomes c. The nurse selects evidence-based nursing interventions d. The nurse explains the nursing care plan to the patient e. The nurse assesses the patient's mental status f. The nurse evaluates the patient's outcome achievement

1. B, C, and D: during the outcome indentification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write the expected patient outcomes, select evidence-based nursing interventions, and communicate the nursing care plan. Although all these steps may overlap, formulating and validating nursing diadnoses occur most frequently during the diagnosing step of the nursing process. Assessing mental statis is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process

1. A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statement describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply a. It functions independently of nursing standards, ethics, and state practice acts b. It is based on the principles of the nursing process, problem solving, and the scientific method c. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care d. It is not designed to compensate for problems created by human nature, such as medication errors e. It is constantly re-evaluating, self-correcting, and striving for improvement f. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care

1. B, C, and E: critical thinking applied to clinical reasoning and judgement in nursing practice is guided by standards, policies and procedures, and ethic codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve.

1. A nurse is providing health care to patients in a health care facility. Which of these patients are receiving secondary health care? Select all that apply a. A patient enters a community clinic with signs of strep throat b. A patient is admitted to the hospital following a myocardial infarction c. A mother brings her son to the emergency department following a seizure d. A patient with osteogenesis imperfecta is being treated in a medical center e. A mother brings her son to a specialist to correct a congenital heart defect f. A woman with a hernia repair in an ambulatory care center

1. B, C, and F: secondary health care treats problems that require specialized clinical expertise, such as an MI, a seizure, and a hernia repair. Treating strep throat is primary health care. Tertiary health care involves management of rare and complex disorders, such as osteogenesis imperfecta and congenital heart malformations

1. A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply a. Refrain from exercise b. Reduce anxiety c. Eat meals 1 to 2 hours prior to breathing treatments d. Eat a high-protein/. High calorie diet e. Maintain a high fowlers position when possible f. Drink 2 to 3 pints of clear fluid daily.

1. B, D, and E: When caring for patients with COPD, it is important t create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/ high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high fowlers position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises and drinking 2 to 3 quarts of clear fluids daily is recommended.

1. A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply a. A nurse sits down with a patient and prioritizes existing diagnoses b. A nurse assesses a woman for postpartum depression during routine care c. A nurse plans interventions for a patient who is diagnosed with epilepsy d. A busy nurse take time to speak to a patient who received bad news e. A nurse reassesses a patient whose PRN pain medications is not working f. A nurse coordinates the home care of a patient being discharged

1. B, D, and E: informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged

1. A registered nurse is writing a diagnosis for a patient who is in traction because of multiple fractures from a motor vehicle accident. Which nursing action are related to this step in the nursing process? Select all that apply a. The nurse uses the nursing interview to collect patient data b. The nurse analyzes data collected in the nursing assessment c. The nurse develops a care plan for the patient d. The nurse points out the patient's strengths e. The nurse assesses the patient's mental status f. The nurse identifies community resources to help his family cope

1. B, D, and F: The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes: identify factors that contribute to or cause health problems (etiologies): and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use data in the assessment step and develops a care plan in the planning step of the nursing process.

1. A nurse working in a community health clinic writes nursing diagnoses for patients and their families. Which nursing diagnoses are correctly written as three-part nursing diagnoses? 1. Disabled family coping related to lack of knowledge about home care of a child on ventilator 2. Imbalanced nutrition: less than body requirements related to inadequate caloric intake while striving to excel in gymnastic program, and greatly less than ideal body weight charts 3. Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3 month hospital stay as evidenced by repeated comments "I cannot do this," " I know I'll harm her because I'm not a nurse," and "I can't do medical things." 4. Spiritual distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "how could god do this to me?" "I don't deserve this," "I don't understand. I've tried to live my life well," and "how could God make me suffer this way?" 5. Caregiver role strain related to failure of home health aides to appropriately diagnose needs of family caregiver's loss of weight and clinical depression a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, 4, and 5

1. B: 1 is a two-part diagnosis, 3 is written in terms of needs and not an unhealthy response, and 5 is legally inadvisable statement which blames home health aides for the patient's problem. Statements that may be interpreted as libel or that imply nursing negligence are legally hazardous to all the nurses caring for the patient. Assigning blame in the written record is problematic.

1. A nurse makes a clinical judgement that an African American man in a stressful job is more vulnerable to developing hypertension than a white man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis? a. Actual b. Risk c. Possible d. Wellness

1. B: A clinical judgement that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a risk nursing diagnosis

1. A nurse is performing an initial comprehensive assessment of a patient admitted to a long term care facility from home. The nurse begins the assessment by asking the patient, "how would you describe your health status and well-being?" the nurse also asks the patient, "what do you do to keep yourself healthy?" which model of organizing data is this nurse following? a. Maslow's human needs b. Gordon's functional health patterns c. Human response patterns d. Body system model

1. B: Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

1. A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? a. Actual b. Potential c. Risk d. Collaborative

1. B: an intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Intervention for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse and physician prescribed interventions.

1. A nurse is performing pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing care? a. Administer pain medication b. Reassess the patient c. Prepare the equipment Explain the procedure to the patient

1. B: before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and, if necessary, administer pain medications

1. The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "how is Mrs. Barclay today? Are our nursing actions helping her achieve her goals? How can we better help her?" this demonstrates which characteristic of the nursing process? a. Systematic b. Interpersonal c. Dynamic d. Universally applicable in nursing situations

1. B: interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking best illustrates the interpersonal dimension of the nursing process.

1. A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get a good baseline data. What would be the instructor's best reply? a. "there's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep." b. "you make the basic questions a part of you and then you learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c. "no one ever really learns how to do this well because each history is different! I often feel like I'm starting fresh with each new patient." d. "don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

1. B: once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer D is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking

1. A nurse is caring for patients in a primary care center. What is the most likely role of this nurse based on the setting? a. Assisting with major surgery b. Performing a health assessment c. Maintaining patients' function and independence d. Keeping student immunization records up to date

1. B: performing patient health assessments is a common role of the nurse in a primary care center. Assisting with major surgery is role of the nurse in the hospital setting. Maintaining patients' function and independence is role of the nurse in an extended-care facility, and keeping student immunization records up to date is the role of the school nurse.

1. A nurse is caring for a patient who has been hospitalized for an asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? a. Thoracentesis b. Pulse oximetry c. Diffusion capacity d. Maximal respiratory pressure

1. B: pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at bedside with the nurse assisting, or in the radiology department.

1. Nurses use the NIC taxonomy structure as a resource when planning nursing care for patients. What information is found in this structure? a. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings c. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention d. A complete list of reimbursable charges for each nursing intervention

1. B: the NIC taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.

1. A nurse working in a pediatric clinic provides codes for a patient's services to a third party payer who pays all or most of the care. This is an example of what mode of health care payment? a. Out-of-pocket payment b. Individual private insurance c. Employer-based group private insurance d. Government financing

1. B: the four basic modes of paying for health care are out-of-pocket payment, individual private insurance, employer-based group private insurance, and government financing. With individual private practice insurance, members pay monthly premiums either by themselves or in combination with employer

1. A friend of a nurse calls and tells the nurse that his girlfriend's father was just admitted to the hospital as a patient, and he wants the nurse to provide information about the man's condition. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? a. "you shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." b. "sorry, but I'm not able to give information about patients to the public-even when my best friend or a family member ask." c. "because of HIPAA, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" d. "why do you think Sue isn't talking about her worries?"

1. B: the nurse should immediately clarify what he or she can and cannot do. Since the primary reason for refusing to help is linked to the responsibility to protect patient privacy and confidentiality, the nurse should not begin by mentioning the real penalties linked to abuses of privacy. Finally, it is appropriate to ask about Sue and her worries, but this should be done after the nurse clarifies what he or she is able to do."

1. A nurse is documenting the care given to a patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidently documents that a dressing change was performed on the left leg. What would be the best action of the nurse to correct this documentation? a. Erase or use correcting fluid to completely delete the error b. Mark the entry "mistaken in error": add correct information: date and initial c. Use permanent marker to block out the mistaken entry and rewrite it d. Remove the page with the error and rewrite the data on that page correctly

1. B: the nurse should not use dittos, erasures, or correcting fluids when correcting documentation: block out a mistake with a permanent marker, or remove a page with an error and rewrite the data on a new page. To correct an error after it has been entered, the nurse should mark the entry "mistaken entry." Add the correct information in the wrong chart, the nurse should write "mistaken entry-wrong chart" and sign off. The nurse should follow similar guidelines in electronic records

1. A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? a. The age of the patient b. The size of the endotracheal tube c. The type of the secretions to be suctioned d. The height and the weight of the patient

1. B: the nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxia.

1. A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? a. Offer the patient 60 mL fluid every 2 hours while awake b. During the next 24 hour period, the patient's fluid intake will total at least 2,000 mL c. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20 d. At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day

1. B: the outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: "offer the patient 60 mL fluid every 2 hours while awake, beginning 1/3/20." The outcome of (d) makes the error of using verbs that are not observable and measurable. Verbs need to be avoided when writing outcomes include "know," "understand," "learn," and "become aware."

1. An emergency department nurse is using a manual resuscitation bag (ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? a. Tilt the patient's head forward b. Hold the mask tightly over the patient's nose and mouth c. Pull the patient's jaw backward d. Compress the bag twice the normal respiratory rate for the patient.

1. B: with the patient's head tilted back, jaw pulled forward, and the airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (16 to 20 breaths per minute)

1. The nurse is helping a patient turn in bed and notices the patient's heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? a. Initial planning b. Standardized planning c. Ongoing planning d. Discharge planning

1. C Ongoing planning is a problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning , the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self- care behaviors competently at home

1. A nurse performs nurse-initiated nursing actions when caring for patients in a skill nursing facility. Which are examples of these types of interventions? Select all that apply a. A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia b. A nurse consults with a psychiatrist for a patient who abuses pain killers c. A nurse checks the skin of bedridden patients for skin breakdown d. A nurse orders a kosher meal for an orthodox Jewish patient e. A nurse records the I & O of a patient as prescribed by his health care provider f. A nurse prepares a patient for minor surgery according to facility protocol

1. C, D, and F: nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing care plan, as well as any other actions that nurses care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention

1. A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10 mg morphine IV every 3-4 hours. Which examples of documentation of care for this patient follow recommended guidelines? Select all that apply a. 6/12/20 0945 morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick RN b. 6/12/20 0945 morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick RN c. 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as a 2 on a scale of 1 to 10. M. Patrick RN d. 6/12/20 0945 patient reports severe pain in right lower quadrant. M. Patrick RN e. 6/12/20 0945 morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick RN f. 6/12/20 0945 patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick RN

1. C, D, and F: the nurse should enter information in a complete, accurate, concise, and factual manner and indicate each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "patient's response to pain appears to be exaggerated" or "seems to be comfortable." The nurse should never document an intervention before carrying it out.

1. Nursing students are reviewing information about health care delivery systems in preparation for a quiz the next day. Which statements describe current US health care delivery practices? Select all that apply a. Access the care depends only on the ability to pay, not the ability of services b. The patient protection and affordable care act provides private health care insurance to underserved populations c. Every health insurance plan in the health insurance market place offers comprehensive coverage, from doctors to medications to hospital visits d. The underinsured pay for more than one third of their care out of pocket and are usually charged lower amounts for their care then the insured pay e. Fifty years ago, half of the doctors in the united states practiced primary care, but today fewer than one in three do f. Quality of care can be defined as the right care for the right person at the right time

1. C, E, and F: The health insurance marketplace is designed to help people more easily find health insurance that fits their budget. Every health insurance plan in the marketplace offers comprehensive coverage, from doctors to medications to hospital visits. Fifty years ago, half of the doctors in the United States practiced primary care, but today fewer than one in three do. Quality is the right care for the right person at the right time. Access to care depends on both the ability to pay and the availability of services. The patient protection and affordable care act provides Medicaid or subsidized coverage to qualifying people with incomes up to 400 % of proverty. The underinsured pay for more than one third of their care out of pocket and are often charged higher amounts for their care than the insured pay

1. A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? a. A postoperative child b. An adult with COPD c. A teenager with cystic fibrosis d. A child with pneumonia

1. C: Chest physiotherapy may help loosen and mobilize secretions, increasing mucous clearance. This is especially helpful for patients with large amounts of secretions or an effective cough such as patients with cystic fibrosis. Chest physiotherapy has limited evidence for its effectiveness and is not recommended for use in numerous patient populations, including children with pneumonia, adults with COPD, and postoperative adults.

1. A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? a. Patient-centered care b. Evidence-based practice c. Quality improvement d. Informatics

1. C: Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

1. A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the best description of the "concepts" that are being diagrammed in this plan? a. Protocols for treating the patient problem b. Standardized treatment guidelines c. The nurse's ideas about the patient problem and treatment d. Clinical pathways for the treatment of sickle cell anemia

1. C: a concept map care plan is a diagram of patient problems and interventions. The nurse's ideas about patient problems and treatment are the "concepts" that are diagrammed. These maps are used to organized patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patient's situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also being diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.

1. The nurse practices using critical thinking indicators (CTIs) when caring for patients sin the hospital setting. The best description of CTIs is: a. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice b. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote. Critical thinking in clinical practice d. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

1. C: evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice

1. A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and then asks the nurse to document it on the health care provider's order sheet. What is the BEST response? a. State: "thank you for taking care of this! I'll be happy to document the order on the health care provider's order sheet." b. Get a second nurse to listen to the order, and after writing the order on the health care provider order sheet, have both nurses sign it. c. State: " I'm sorry, but Vos can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." d. Try calling another resident for the order or wait until the next shift

1. C: in most facilities, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician or NP is present but finds it impossible, due to the emergency situation, to write the order. Trying to call another resident for the order or waiting until the next shift would be inappropriate: the patient should not have to wait for the pain medication, and a resident is available who can immediately write the order.

1. A female patient who is receiving chemotherapy for breast cancer tells the nurse, "the treatment for this is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address the patient problem. Which action is the first step the nurse would take in this process? a. The nurse judges whether the patient database is adequate to address the problem. b. The nurse considers whether or not to suggest a counseling session for the patient c. The nurse reassesses the patient and decides how best to intervene in her care. d. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

1. C: the first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts towards the goal. Once the problem is addresses, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.

1. A nurse cares for dying patients by providing physical, psychological, social, and spiritual care for the patients, their families, and other loved ones. What type of care is the nurse providing? a. Respite care b. Palliative care c. Hospice care d. Extended care

1. C: the hospice nurse combines the skills of the home care nurse with the ability to provide daily emotional support to dying patients and their families. Respite care is a type of care provided for caregivers of homebound ill, disabled, or older adults. Palliative care, which can be used in conjunction with medical treatment and in all types of health care settings, is focused on the relief of physical, mental, and spiritual distress. Extended-care facilities include transitional subacute care, assisted living facilities, intermediate and long-term care, homes for medically fragile children, retirement centers, and residential institutions for mentally and developmentally or physically disabled patients of all ages

1. A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? a. The nurse assures that the oxygen is flowing into the prongs b. The nurse adjusts the fit of the cannula, so it fits snug and tight against the skin c. The nurse encourages the patient to breathe through the nose with the mouth closed d. The nurse adjusts the flow rate to 6 L/min or more.

1. C: the nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula, so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered.

1. The nurse is surprised to detect an elevated temperature (102 F) in a patient who is scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? a. Inform the charge nurse b. Inform the surgeon c. Validate the finding d. Document the finding

1. C: the nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.

1. A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial assessment. What is the best response of the new RN? a. Allow the UAPs to do the admission assessment and report the findings to the RN b. Do his or her own admission assessment but don't interfere with the practice if other professional RNs seem comfortable with the practice c. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration d. Contact his or her labor representative to report this practice to the state board of nursing

1. C: the nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

1. A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? a. Instruct the assistant to notify the primary care provider b. Assess the patient's vital signs c. Remove the tape, adjust the depth to the ordered depth and reapply the tape d. No action is required as depth will adjust automatically

1. C: the tube depth should be maintained at the same level unless otherwise ordered by the health care provider. If the depth changes, the nurse should remove the tape, adjust the tube ordered depth, and reapply the tape.

1. A nurse develops a detailed care plan for a 16 year old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "we will be fine on our own. I don't need any more care." What would the nurse's best response ? a. "you know your personal situation better than I do, so I will respect your wishes." b. "if you don't accept these services, your babies health will suffer." c. "let's take a look at the plan again and see if we can adjust it to fit your needs." d. "I'm going to assign your care to a social worker who can explain the services better."

1. C: when a patient does not follow the care plan despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the care plan is adequate, the nurse must identify and remedy the factors contributing to the patient's non compliance

1. A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr Sanchez, a patient who has been prescribed morphine via a patient controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the correct ISBARR order a. "I am calling about Mr. Sanchez in room 202 who is receiving morphine via a PCA pump for pancreatic cancer." b. "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." c. "you want me to discontinue the PCA pump until you see him tonight at patient rounds." d. "I am Rosa Clark, an RN working on the second floor of south street hospital." e. "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." f. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered"

1. D, A, E, B, F and C: The order for ISBARR is: Identify/ introduction, Situation, Background, Assessment, Recommendation and Read-back.

1. A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply a. "I will be careful not to shake up the canister before using it." b. "I will hold the canister upside down when using it." c. "I will inhale the medication through my nose." d. "I will continue to inhale when the cold propellant is in my throat." e. "I will only inhale one spray with one breath." f. "I will activate the device while continuing to inhale."

1. D, E, and F: common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.

1. A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? a. Every 3 hours b. Every 4 hours c. Daily d. As needed

1. D: PRN means "as needed"- not every 3 or 4 hours or daily

1. A nurse working in a long term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? a. Travelbee's b. Watson's c. Benner's d. Swanson's

1. D: Swanson identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility." Travelbee, an early nurse theorist, developed the human to human relationship model, and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel wrote that caring is a basic way of being in the world, and that caring is central to human expertise, curing, and healing. Watson's theory is based on the belief that all humans are to be valued, cared fo, respected, nutured, understood, and assisted.

1. The nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? a. "I'm sorry, but patients are not allowed to copy their medical records." b. "I can make a copy of your record for you right now." c. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." d. "I will need to check with our records department to get you a copy."

1. D: according to HIPAA, patients have a right to see and copy their health record: update their health record: get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations: request a restriction on certain uses or disclosures: and choose how to receive health information. The nurse should be aware of facility policies regarding the patient's right to access and copy records.

1. A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? a. Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge b. By 6/12/20, the patient will correctly demonstrate application of wet to dry dressing on leg ulcer c. By 6/19/20, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5in) d. By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer

1. D: affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors: psychomotor outcomes (b) describe the patient's achievement of new skills: and (c) is an outcome describing a physical change in the patient

1. A student nurse is organizing clinical responsibilities for a patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today, I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? a. Explain the patient that there is not enough time to wash her hair today because of her busy schedule b. Schedule the testing and meal planning first and complete hygiene as time permits c. Perform a dressing change first, schedule the testing and counseling, and complete hygiene last d. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counselling.

1. D: as long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being the most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership

1. A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which. Nursing diagnoses are correctly written as a two-part nursing diagnosis. 1. Ineffective coping related to inability to maintain marriage 2. Defensive coping related to loss of job and economic security 3. Altered thought processes related to panic state 4. Decisional conflict related to placement of parent in a long-term facility a. 1 and 2 b. 3 and 4 c. 1, 2, and 3 d. 1, 2, 3 and 4

1. D: each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology cause.

1. A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? a. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone b. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability c. Teach the patient to take short shallow breaths when performing hygiene measures d. Group personal care activities into smaller steps, allowing rest periods between activities

1. D: for the patient who is too fatigued to complete daily hygiene on his or her own, the nurse should group personal care activities into smaller steps and allow rest periods between activities. The nurse should assist with bathing and hygiene tasks as needed and only when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits and teach the patient to coordinate diaphragmatic breathing with the activity.

1. A nurse notes that a shift report states that a patient has no special skin needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? a. Correct the initial assessment b. Redo the initial assessment and document the current findings c. Conduct and document an emergency assessment d. Perform and document a focused assessment of skin integrity

1. D: perform and document a focused assessment on the skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.

1. When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? a. Thank the wife for being present b. Ask the wife is she wants to remain c. Ask the wife to leave d. Ask the patient if he would like the wife to stay

1. D: the patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse should neither presume that he wants his wife there now that he does not want her there. Similarily, the choice belongs to the patient, not the wife

1. A nurse is providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? a. Notify the healthcare provider b. Apply an occlusive dressing on the site c. Assess the patient for signs of respiratory distress d. Put on gloves and insert the chest tube in a bottle of sterile saline

1. D: when a chest tube becomes separated from the drainage device, the nurse should submerge the end in water, creating a water seal, but allowing air to escape, until a new drainage unit can be attached. This is done instead of clamping to prevent another pneumothorax. Then the nurse should assess vital signs and notify the health care provider.

1. A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a. The patient vomits during suctioning b. The secretions appear to be stomach contents c. The catheter touches unsterile surface d. A nosebleed is noted with continued suctioning

1. D: when nosebleed (epistaxis) is noted with continued suctioning, the nurse should notify the health care provide and anticipate the need for nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning

A nurse is looking for trends in a postoperative patient's vital signs. which documents would the nurse consult first? a. Admission sheet b. Admission nursing assessment c. Flow sheet d. Graphic record

1. D: while one recording of vital signs should appear on the admission nursing assessment, the best place to find sequential recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign documentation, and neither does the flow sheet.

2. A nurse is caring for a patient who presents with labored respirations, productive cough, and a fever. What would be appropriate nursing diagnosis for this patient? Select all that apply a. Bronchial pneumonia b. Impaired gas exchange c. Ineffective airway clearance d. Potential complications: sepsis e. Infection related to pneumonia f. Risk for septic shock

2. B, C, and F: Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem

3. After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? a. No problem b. Possible problem c. Actual nursing diagnosis d. Clinical problem other than nursing diagnosis

3. B: When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.

4. A nurse assesses a patient and formulates the following nursing diagnosis: Risk for impaired skin integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? a. Risk for impaired skin integrity b. Related to prescribed bed rest c. As evidenced by d. As evidenced by reddened areas of skin on the heels and back

4. B: "related to prescribed bed rest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "risk for impaired skin integrity" is the problem, and "as evidence by reddened areas of skin on the heels and back" are the defining characteristics the problem.

5. A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing my bag." The nurse diagnoses altered health maintenance. This is an example of what type of problem? a. Collaborative problem b. Interdisciplinary problem c. Medical problem d. Nursing problem

5. D: Altered health maintenance is a nursing problem, because the diagnosis describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.

6. The nurse records a patient's blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading? a. Compare this reading to standards b. Check the taxonomy of nursing diagnoses for a patient's label c. Check a medical text for the signs and symptoms of high blood pressure d. Consult with colleagues

6. A: A standard, or a norm, is generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading. Appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis