Prioritization, Nursing Process, Delegation

Which of the following is a direct care intervention? A. Administration of an injection B. Making the change-of-shift report C. Collaborating with members of the health care team D. Ensuring availability of needed equipment

A. Administration of an injection

During a patient's bath, the nurse observes the patient having a tonic clonic seizure. The nurse immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

C. Implementation

A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take? 1. Immobilize the affected limb with a splint and ask him not to move. 2. Make a thorough assessment of the circumstances surrounding the accident. 3. Put him in semi-Fowler's position for comfort. 4. Check the pedal pulse and blanching sign in both legs.

1. Immobilize the affected limb with a splint and ask him not to move.

A child undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought to the recovery room. Which of the following actions should the nurse include in the child's plan of care? 1. Institute measures to minimize crying. 2. Perform postural drainage every 2 hours. 3. Cough and deep-breathe every hour. 4. Give ice cream as tolerated.

1. Institute measures to minimize crying.

In which step of the nursing process does the nurse provide nursing care interventions to patients? A. Assessment B. Planning C. Implementation D. Evaluation

C. Implementation

The nurse is reviewing the last 3 days of a patient's pain history and notes that the pain level has remained constant. The nurse validates the pain level with the patient and decides to contact the physician for further orders. In this scenario the nurse is using the process of: A. decision making. B. reasoning. C. problem solving. D. judgment.

D. judgment.

The nurse obtains a diet history from a pregnant 16-year-old girl. The girl tells the nurse that her typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a cheeseburger, milk shake, fries, and salad for dinner. Which of the following is the MOST accurate nursing diagnosis based on this data? 1. Altered nutrition: more than body requirements related to high-fat intake 2. Knowledge deficit: nutrition in pregnancy 3. Altered nutrition: less than body requirements related to increased nutritional demands of pregnancy 4. Risk for injury: fetal malnutrition related to poor maternal diet

3. Altered nutrition: less than body requirements related to increased nutritional demands of pregnancy

An hour after admission to the nursery, the nurse observes a newborn baby having spontaneous jerky movements of the limbs. The infant's mother had gestational diabetes mellitus (GDM) during pregnancy. Which of the following actions should the nurse take FIRST? 1. Give dextrose water. 2. Call the physician immediately. 3. Determine the blood glucose level. 4. Observe closely for other symptoms.

3. Determine the blood glucose level.

After change of shift, you are assigned to care for the following patients. Which patient should you assess first? A 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab A 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation A 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

A 50-year old with asthma who complains of shortness of breath after using a bronchodilator

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months experience) pulled from the surgical unit to the medical unit? A 58-year old on airborne precautions for tuberculosis (TB) A 68-year old just returned from bronchoscopy and biopsy A 72-year old who needs teaching about the use of incentive spirometry A 69-year old with COPD who is ventilator dependent

A 72-year old who needs teaching about the use of incentive spirometry

A new nurse is reviewing her patient assignments for the day. Which patient should the nurse assess first? A patient having urinary retention related to BPH A newly admitted patient with acute flank pain and hematuria A patient who underwent a renal biopsy two days ago A patient undergoing hemodialysis later today

A newly admitted patient with acute flank pain and hematuria

An example of a measurable goal would be: A. "The patient will be able to lift 10 lb by October 19th 1500." B. "The patient will be able to lift weights by October 19th 1500 ." C. "The patient will be able to lift his normal weight amount." D. "The patient will be able to lift an acceptable amount of weight by week one."

A. "The patient will be able to lift 10 lb by October 19th 1500."

A client is admitted to the emergency department with a rash on the trunk and extremities. The client reports difficulty​ breathing, chest​ tightness, and weakness. Respirations are 24​ breaths/min and​ even, pulse is 90​ beats/min and​ thready, and blood pressure is​ 96/70 mmHg. The client reports a recent history of a urinary tract infection and having been on sulfasalazine for the past 5 days. Which is the priority nursing assessment for this​ client? A. Airway patency B. Peripheral edema C. Urine discoloration D. Gastrointestinal disturbances

A. Airway patency

A patient in respiratory distress is being cared for by a RN, an LPN, and a nursing assistant. The nursing assistant checks the patient's pulse oximetry level as requested by the RN. The patient's reading is 88%. There is an order for oxygen, 1-4L, if the patient's oxygen level is sustained below 90%. The RN is busy assessing a critical patient, what should she do next? A. Ask the LPN to obtain the patient's vital signs and apply a nasal cannula at 2L/min B. Complete the current task then see the patient C. Ask the nursing assistant to administer oxygen to the patient D. Stop assessing her critical patient and apply a nasal cannula to her other patient

A. Ask the LPN to obtain the patient's vital signs and apply a nasal cannula at 2L/min

Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's first action? A. Assess the patient for other symptoms or problems, and then notify the health care provider. B. Review the most recent lab results for the patient's potassium level. C. Follow the clinical protocol for a stroke. D. Administer an antihypertensive medication from the stock supply, and then notify the health care provider.

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

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

A. Assessment

A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

A. Assessment

The nurse working in a community clinic is reviewing the clients to be seen for the day. Which client should require more time in the​ schedule? A. A​ 75-year-old with recent cognitive decline B. A​ 20-year-old who is being seen for evaluation of insulin pump management C. A​ 50-year-old who is being seen for blood pressure recheck D. A​ 32-year-old with newly diagnosed diabetes who is returning for a blood glucose recheck

A. A​ 75-year-old with recent cognitive decline

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse A. Completes a comprehensive database. B. Identifies pertinent nursing diagnoses. C. Intervenes based on patient goals and priorities of care. D. Determines whether outcomes have been achieved.

A. Completes a comprehensive database.

The nurse develops a list of nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, "I understand that I will lose most of my hair. Will it grow back?" Which of the following diagnoses will address this statement? A. Disturbed body image B. Nausea C. Risk for bleeding D. Imbalanced nutrition: less than body requirements

A. Disturbed body image

The nurse is considering asking the patient for permission to involve the patient's family members in the teaching plan for the patient. Which of the following is the best rationale to support this involvement? A. Involving the family in effective teaching empowers the patient and their support system. B. Teaching family members decreases the number of questions they may ask. C. Educated family members choose not to become part of the health care process. D. The education is interesting although family do not usually care for patients after discharge.

A. Involving the family in effective teaching empowers the patient and their support system.

Which action by the nurse can help to avoid pitfalls that can result in client​ harm? (Select all that​ apply.) A. Knowing client healthcare concerns B. Prioritizing client care appropriately C. Delegating care only when absolutely necessary D. Incorporating client preferences as possible when prioritizing care E. Following ethical care practices

A. Knowing client healthcare concerns B. Prioritizing client care appropriately D. Incorporating client preferences as possible when prioritizing care E. Following ethical care practices

Which action should the nurse take to best involve hospitalized clients in their care and avoid pitfalls related to not involving clients in their own​ care? A. Observing client behaviors for cues about preferences B. Asking the​ client's family about usual patterns of behavior C. Orienting the client and family to the hospital facility and routines D. Informing clients of the daily schedule of care

A. Observing client behaviors for cues about preferences

The nurse manager is creating the patient assignment for today. She has five registered nurses (RNs), two licensed practical nurses (LPNs), and five nurse technicians (NAs) scheduled. When making the assignment, the nurse manager needs to remember that: A. RNs are responsible for all care delegated to unlicensed nursing personnel. B. delegation is considered direct intervention for patient care. C. LPNs operate independently and may delegate patient care. D. nursing practice is clearly delineated and is standard across the country.

A. RNs are responsible for all care delegated to unlicensed nursing personnel.

A new graduate nurse is having difficulty prioritizing care and leaving the shift in a timely manner. The nurse manager notes that the new nurse rarely delegates tasks to the unlicensed assistive personnel​ (UAP) since a recent incident in which the new nurse delegated an inappropriate task to a UAP. Which action by the nurse manager should best help to address this​ situation? A. Reviewing state and facility guidelines concerning delegation with the nurse B. Encouraging the nurse not to let the recent experience impact future actions C. Having the UAP discuss with the nurse appropriate activities that he can do to assist the nurse with client care D. Reminding the nurse that she will quickly burn out if she does not delegate some care to the UAP

A. Reviewing state and facility guidelines concerning delegation with the nurse

The nurse prioritizes care for a client with diabetes mellitus using​ Maslow's hierarchy of needs. Which need is identified as the priority for this​ client? A. The nurse teaches the client how to properly change dressings on the​ right-leg amputation site. B. The client joins the local American Diabetes Association support group. C. The client attends classes to deal with body image after amputation of the right leg. D. The nurse teaches the client proper home safety techniques to prevent diabetic wounds.

A. The nurse teaches the client how to properly change dressings on the​ right-leg amputation site.

The nurse has many roles. One is to support and work on behalf of patients for whom he/she has concern. This role is known as: A. advocate. B. primary care provider. C. collaborator. D. delegator.

A. advocate.

Patients should be included in the planning process. Involving patients in planning their care helps them to: (Select all that apply.) A. be aware of identified needs. B. accept that not all goals are measurable. C. embrace mutually agreed-on goals. D. feel a sense of empowerment. E. overcome unrealistic goals.

A. be aware of identified needs. C. embrace mutually agreed-on goals. D. feel a sense of empowerment.

Physical therapy, home health care, and Case Management are examples of: A. collaborative interventions. B. dependent nursing interventions. C. independent nursing interventions. D. assessment data.

A. collaborative interventions.

After the nurse completes a patient's initial assessment and develops a plan of care: A. continual reassessment of the patient is required. B. no changes to the care interventions should be allowed. C. reassessment should be done randomly. D. the nursing process becomes static to maintain the course of the cure.

A. continual reassessment of the patient is required.

The patient is complaining of severe incisional pain 2 days after surgery. The patient has Morphine ordered intravenously or by mouth. The nurse chooses to give the medication orally. This is an example of: A. decision making. B. reasoning. C. problem solving. D. judgment.

A. decision making. Decision making requires choosing a solution to a problem. Reasoning is the process by which a nurse determines a patient's health status after gathering data and applying meaning to behaviors and physical signs and symptoms. A systematic approach in finding solutions is termed problem solving, and judgment is the process of forming an opinion by comparing solutions through reasoning. Nurses use Clinical decision making whenever choices are available

Nursing interventions that originate from the physician or primary care provider orders are: A. dependent B. independent C. collaborative D. Nursing Interventions Classifications

A. dependent

To develop critical thinking, the nurse needs to develop a critical-thinking character that includes: A. developing integrity and confidence. B. learning from experiences. C. enhancing self-reliance. D. growing a "thick skin" to withstand criticism.

A. developing integrity and confidence.

Establishing short- and long-term goals to address nursing diagnoses involves: (Select all that apply.) A. discussion with the patient. B. exclusion of family with making patient decisions. C. collaboration with other members of health care team. D. making the health care provider as the central figure. E. coordination of care as collaborative care.

A. discussion with the patient. C. collaboration with other members of health care team. E. coordination of care as collaborative care.

The nurse is attempting to develop nursing diagnoses for her patient. The nurse understands that nursing diagnoses: (Select all that apply.) A. identify actual or potential problems as well as responses to a problem. B. require naming patient problems using nursing diagnostic labels. C. includes unvalidated data to determine an accurate and thorough diagnosis. D. are similar to medical diagnoses since they both are labels for diseases.

A. identify actual or potential problems as well as responses to a problem. B. require naming patient problems using nursing diagnostic labels.

Change of shift report, collaboration with other health care members, and ensuring availability of needed equipment are examples of: A. indirect care. B. direct care. C. referrals. D. delegation

A. indirect care.

Setting priorities among identified nursing diagnoses is the first step in the planning process. The nurse A. monitoring patient responses. B. carrying out the physician's plan of care. C. providing all interventions. D. preventing interference from other disciplines.

A. monitoring patient responses.

The nurse knows that standardized care plans may be available and: A. need to be individualized for each patient. B. are implemented without adjustment. C. remove the need for nurse involvement. D. do not require the use of nursing diagnoses.

A. need to be individualized for each patient.

The five rights of delegation include: A. right task, right circumstance, right person, right direction, and right supervision B. right medication, right route, right time, right patient, and right dose C. right task, right route, right patient, right direction, and right medication D. right role, right job, right task, right need, and right dose

A. right task, right circumstance, right person, right direction, and right supervision

Measurable goals are: (Select all that apply.) A. specific B. time limited C. vague D. achievable E. relevant

A. specific B. time limited D. achievable E. relevant

A patient is preparing for an orthopaedics surgery and the LPN is asked to help. For which of the following tasks must the RN confirm that the LPN has received special training? Collecting a urine specimen Assisting the patient with a bath Ambulating the patient Administering I.V. therapy

Administering I.V. therapy

A patient in respiratory distress is being cared for by a RN, an LPN, and a nursing assistant. The nursing assistant checks the patient's pulse oximetry level as requested by the RN. The patient's reading is 88%. There is an order for oxygen, 1-4L, if the patient's oxygen level is sustained below 90%. The RN is busy assessing a critical patient, what should she do next? Ask the LPN to obtain the patient's vital signs and apply a nasal cannula at 2L/min Complete the current task then see the patient Ask the nursing assistant to administer oxygen to the patient Stop assessing her critical patient and apply a nasal cannula to her other patient

Ask the LPN to obtain the patient's vital signs and apply a nasal cannula at 2L/min

List the five (5) steps of the Nursing Process (In Order):

Assessment, Nursing Diagnosis, Planning, Implementing, Evaluating

A patient with chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to a nursing assistant (PCT)? Assisting the patient to sit up on the side of the bed Instructing the patient to cough effectively Teaching the patient to use incentive spirometry Auscultation of breath sounds every 4 hours

Assisting the patient to sit up on the side of the bed

An experienced LPN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? Select all that apply. Auscultate breath sounds Administer medications via metered-dose inhaler (MDI) Complete in-depth admission assessment Initiate the nursing care plan Evaluate the patient's technique for using MDI's

Auscultate breath sounds Administer medications via metered-dose inhaler (MDI)

Which of the following statements would be considered objective data? (Select all that apply.) A. "I'm short of breath." B. "Blood pressure 90/68, apical pulse 102, skin pale and moist." C. "Lung sounds clear bilaterally, diminished in right lower lobe." D. "I feel weak all over when I exert myself." E. "My pain level is down to 2. It was 8."

B. "Blood pressure 90/68, apical pulse 102, skin pale and moist." C. "Lung sounds clear bilaterally, diminished in right lower lobe."

The nurse is organizing care for the day for the assigned clients. Which client should the nurse give highest prioritization to ensure appropriate medication​ administration? A. A client who is receiving daily dialysis B. A client receiving several intravenous​ antibiotics, each to be infused over 30-60 minutes C. A client with diabetes requiring insulin coverage QID D. A client with unstable vital signs receiving multiple blood pressure medications

B. A client receiving several intravenous​ antibiotics, each to be infused over 30-60 minutes

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

C. Health promotion

The nurse is prioritizing client care as​ low, medium, or high priority for the current assignment. Which client should the nurse identify as having a ​high-priority​ circumstance? (Select all that​ apply.) A. A client who is experiencing extreme bouts of diarrhea B. A client with emphysema and a pulse oximeter reading of 88 C. An extremely confused older client D. A client who is receiving warfarin​ (Coumadin) E. A client with congestive heart failure and shortness of breath

B. A client with emphysema and a pulse oximeter reading of 88 D. A client who is receiving warfarin​ (Coumadin) E. A client with congestive heart failure and shortness of breath

Which client should the nurse assess first after receiving the​ change-of-shift report? A. A client with a bowel obstruction who is complaining of nausea B. A client with heart failure who is complaining of shortness of breath C. A client with hypertension with a blood pressure of​ 168/88 mmHg D. A client with type 1 diabetes mellitus with blood glucose of 82​ mg/dL

B. A client with heart failure who is complaining of shortness of breath

Which of these patient scenarios is most indicative of critical thinking? A. Administering pain relief medication according to what was given last shift B. Asking a patient what pain relief methods, pharmacological and nonpharmacological, have worked in the past C. Offering pain relief medication based on physician orders D. Explaining to the patient that his reports of severe pain are not consistent with the minor procedure that was performed

B. Asking a patient what pain relief methods, pharmacological and nonpharmacological, have worked in the past

Which of the following cannot be delegated? A. Obtaining vital signs B. Assessment of lung sounds C. Bathing a patient D. Ambulating a patient

B. Assessment of lung sounds

The nurse administered blood pressure medications to the wrong client. Upon realizing the​ error, the nurse notes that the last blood pressure assessment of the client who received the wrong medication was​ 82/50 mmHg. Which level of urgency would be required to address this​ situation? A. Imminent death B. Critical C. Nonacute D. Acute

B. Critical

Medication administration is what type of nursing intervention? A. Independent B. Dependent C. Collaborative D. Interdisciplinary

B. Dependent

The charge nurse is reviewing a patient's plan of care, which includes the formulation of the nursing diagnosis statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate to bathroom. The nurse needs to revise which part of the diagnostic clause? (Revision means to correct what is incorrect.) A. Nursing diagnosis B. Etiology C. Patient chief complaint D. Defining characteristic

B. Etiology

Which diagnosis below is NANDA-I approved? A. Hypertension B. Impaired Urinary Elimination C. Sore throat D. High blood pressure

B. Impaired Urinary Elimination Impaired Urinary Elimination is the only NANDA-I-approved diagnosis listed. High blood pressure (hypertension) are medical diagnoses, and sore throat is a subjective complaint.

A client presents to the emergency department​ (ED) complaining of pain and burning on urination. The client also tells the triage nurse that she noted blood in the urine the past few times she​ urinated, so she thought she should come to the emergency department. In which category should the nurse classify the​ client's problem to prioritize care in relation to other clients in the​ ED? A. Immediate B. Nonurgent C. Urgent D. Emergent

B. Nonurgent

After completing a thorough database and analyzing the data to identify any problems, the nurse should proceed to what step of the nursing process? A. Assessment B. Planning C. Implementation D. Evaluation

B. Planning

In which step of the nursing process does the nurse prioritize the nursing diagnoses and identify interventions to address the patient goals? A. Assessment B. Planning C. Implementation D. Evaluation

B. Planning

The nurse working on a busy medicaldashsurgical unit is caring for five clients. As the nurse is preparing to administer routine medications to the assigned​ clients, she is informed that a new admission will be arriving to the unit shortly. Which type of situation challenges the​ nurse's time management and organizational​ skills? A. Urgent B. Pop-up C. Emergent D. Pitfall

B. Pop-up

A nurse is caring for a patient with a nursing diagnosis of Disturbed Sensory Perception (auditory) related to inability to discern spoken language. Which assessment of the patient would indicate an adaptation to the sensory deficit? A. The patient frequently cleans out his ears with a cotton swab. B. The patient turns one ear toward the nurse during conversation. C. The patient isolates himself from social situations. D. The patient asks the nurse to speak loudly during conversations.

B. The patient turns one ear toward the nurse during conversation.

After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions? A. To form a language that can be encoded only by nurses B. To distinguish the nurse's role from the physician's role C. To develop clinical judgment based on other's intuition D. To help nurses focus on the scope of medical practice

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

A patient, frequently admitted to the hospital for chronic back pain, asks the medication nurse for additional pain medication. The nurse has seen patients like this before, and "knows" that the only reason that these people come to the hospital is to get their pain medication. The nurse is demonstrating: A. illogical thinking. B. a bias. C. closed-mindedness. D. an erroneous assumption.

B. a bias.

The patient has an order for morphine sulfate 2 mg intravenously prn (as needed) every 2 hours. When the nurse administers this medication, she is providing: A. an independent nursing intervention. B. a dependent nursing intervention. C. a referral D. an indirect care procedure.

B. a dependent nursing intervention.

The nurse is planning the day on a general medical unit. Which activity should the nurse prioritize as​ "must do" and not advisable to be delegated to unlicensed assistive personnel​ (UAP)? A. Assisting clients with hygienic care activities B. Ambulating a stable client to the bathroom C. Health teaching for a client being discharged poststroke D. Collecting vital signs on assigned clients

C. Health teaching for a client being discharged poststroke

The nurse has been practicing for several years and has become the unofficial leader, with newer nurses going to her for advice about patient care. They are amazed at how much the older nurse "thinks like a nurse." In order to "think like a nurse," the nurse must: (Select all that apply.) A. be a nurse for several years. B. be able to apply knowledge in making clinical decisions. C. actively participate in the process. D. accept procedures that have been in place for years as right. E. develop a questioning attitude.

B. be able to apply knowledge in making clinical decisions. C. actively participate in the process. E. develop a questioning attitude.

Repositioning a patient, providing hygiene, and active listening are examples of: A. dependent interventions. B. independent nursing interventions. C. standing orders. D. counseling.

B. independent nursing interventions.

The nursing process is an attempt to meet patient needs. As such, it: A. is linear in nature. B. is dynamic and cyclic. C. requires care plans to be re-evaluated occasionally. D. does not allow care plans to be modified.

B. is dynamic and cyclic. The nursing process is ongoing in an attempt to meet patient needs. The nursing process is not linear in nature but is dynamic and cyclic, constantly adapting to a patient's health status. Care plan modifications may be necessitated due to deterioration or improvement of a patient's condition. The Joint Commission requires patient care plans to be evaluated on a continual basis.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistant. With this in mind, what clinical decision should the nurse make? A. Administer scheduled medications assuming she would have been informed if the vital signs were abnormal. B. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. C. Ask the nursing assistant to record the patient's vital signs before administering medications. D. Omit the vital signs because the patient is presently in no distress.

C. Ask the nursing assistant to record the patient's vital signs before administering medications.

The nurse enters a room to find the patient sitting up in bed crying. How would the nurse display a critical thinking attitude in this situation? A. Tell the patient she'll be back in 30 minutes. B. Set a box of tissues at the patient's bedside before leaving the room. C. Ask the patient why she is crying. D. Limit visitors while the patient is upset.

C. Ask the patient why she is crying.

Which action should the nurse take when using critical thinking to make clinical decisions? A. Make decisions based on intuition. B. Accept one established way to provide care. C. Consider what is important in a given situation. D. Read and follow the heath care provider's orders.

C. Consider what is important in a given situation.

The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a patient scheduled for back surgery. Which step of the nursing process is the nurse addressing? A. Assessment B. Diagnosis C. Implementation D. Evaluation

C. Implementation The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

The nurse recognizes that another term for a collaborative nursing intervention is _____ intervention. A. Dependent B. Independent C. Interdependent D. Physician-initiated

C. Interdependent

The nurse caring for a client with diabetes mellitus receives a report from another nurse that the client is experiencing a hypoglycemic episode. The nurse immediately prepares to administer 50 mL of D50 IVP. Upon entering the​ room, the nurse notes that the client seems alert and does not have any current complaints and decides not to administer the D50. Which pitfall was avoided by the nurse in this​ situation? A. Failure to do periodic assessments B. Incomplete assessment C. Relying solely on​ another's assessment D. Poor time management

C. Relying solely on​ another's assessment

Which assessment made by the nurse should be addressed first? A. Reddened area to coccyx B. Decreased urinary output C. Shortness of breath D. Drainage from surgical incision

C. Shortness of breath

The nurse assesses vital signs for multiple clients. Which assessment and client condition will cause the nurse the most concern? A. The postoperative client medicated 3 hours prior for pain with a blood pressure of 194/88 mm Hg. B. The older adult client diagnosed with bacterial pneumonia with a temperature of 100.8°F (38.2°C). C. The adult client receiving patient controlled administration of morphine who has a respiratory rate of 9 breaths/minute. D. The adult client admitted through the ED following a car accident with a pulse rate of 92 beats/minute.

C. The adult client receiving patient controlled administration of morphine who has a respiratory rate of 9 breaths/minute.

The registered nurse is providing an independent nursing intervention when: A. administering oral medications. B. administering oxygen. C. providing emotional support. D. administering intravenous medication.

C. providing emotional support.

Another RN has called in sick, leaving 10 pediatric cancer patients to be cared for by one RN and 3 nursing assistants. What should the nurse do? Contact the nurse manager and request more nursing assistants Contact the nursing supervisor and request another RN Delegate as much to the nursing assistants as legally possible Plan and organize to maximize efficiency

Contact the nursing supervisor and request another RN

The nurse is providing care for several clients with neurologic dysfunction. Which client should be placed closest to the​ nurses' station? A. A preoperative​ 68-year-old client who was diagnosed with an astrocytoma B. A​ 72-year-old client who is 2 days postoperative for a carotid endarterectomy C. An​ 80-year-old client with viral meningitis who was admitted 3 days ago D. A newly admitted​ 65-year-old client who experienced an acute subdural hematoma

D. A newly admitted​ 65-year-old client who experienced an acute subdural hematoma

The medical-surgical nurse is planning the day immediately after receiving report. Which should be the primary nursing intervention when prioritizing​ care? A. Analyzing collected data B. Ascertaining interventions C. Assigning staff to clients D. Assessing client situations

D. Assessing client situations

The nurse correctly identifies which one of the following referrals as an inappropriate nursing referral? A. Music therapist B. Community agencies C. Adaptive care services D. Dermatologist

D. Dermatologist

A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? A. Ineffective breathing pattern related to pneumonia B. Risk for infection related to chest x-ray procedure C. Risk for deficient fluid volume related to dehydration D. Impaired gas exchange related to alveolar-capillary membrane changes

D. Impaired gas exchange related to alveolar-capillary membrane changes

A homeless client presents to the emergency department​ (ED) complaining of severe chest pain. The client is well known to the​ ED, coming in frequently for various minor complaints. Which ethical principles should be most important for the nurse to​ consider? A. Nonmaleficence and beneficence B. Accountability and responsibility C. Privacy and confidentiality D. Justice and fairness

D. Justice and fairness

The nurse in an emergency department​ (ED) shares with a fellow nurse​ that, due to the busy pace of the​ day, he has not even been able to go to the bathroom since he arrived for his shift 6 hours ago. Which response by the fellow nurse should best address this​ situation? A. Listening to the​ nurse's concerns and offering verbal encouragement to make it through the rest of the shift B. Discussing better ways to prioritize and manage time with the nurse so that in the future he will be able to take needed breaks C. Encouraging the nurse to let the supervisor know so that appropriate actions can be taken D. Offering to oversee the​ nurse's clients so that a​ 15-minute break can be taken

D. Offering to oversee the​ nurse's clients so that a​ 15-minute break can be taken

You have just received nursing report from the previous shift and you are performing your morning patient assessments. You have a total of 4 patients that are either post-op or pre-op for surgery. Which assessment finding requires further nursing action? A. Orange-colored urine in a patient who is taking Pyridium and is post-op day 3 from a TURP. B. No stool excretion in a patient who is post-op day 2 from a colostomy. C. Shoulder pain in a patient who is post-op day 1 from a laparoscopic cholecystectomy. D. Pain rating that has decreased from a 10 to 1 in a patient who is awaiting an appendectomy.

D. Pain rating that has decreased from a 10 to 1 in a patient who is awaiting an appendectomy.

The nurse is assessing a​ client's peripheral circulation after cardiac catheterization. Which finding is the highest​ priority? A. The femoral site is soft and free of hematoma or bleeding. B. The​ client's toes are warm and pink. C. Pulses are palpable and bounding. D. The client is experiencing numbness in the toes.

D. The client is experiencing numbness in the toes.

The nurse is caring for a patient with blindness. When reviewing the care plan, the nurse notes which of the following goals need to be modified? A. The patient will report any drainage from the wound with a foul odor to the primary care provider after discharge. B. The patient will agree to report pain promptly while hospitalized. C. The patient will obtain no injuries while in the hospital. D. The patient will report any wound drainage with a purulent appearance to the primary care provider after discharge.

D. The patient will report any wound drainage with a purulent appearance to the primary care provider after discharge.

The following statements are on a patient's nursing care plan. Which of the following statements is written as an appropriate goal and outcome? A. The patient will understand needed dietary changes by October 20, 2018, 1500 B. The patient will demonstrate increased mobility in 2 days. C. The patient will demonstrate increased tolerance to activity over the next month. D. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by October 20, 2018, 1500.

D. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by October 20, 2018, 1500.

The nurse has received advanced orders for a patient that she is expecting to be admitted from the emergency room (ER). The patient's name is Mr. Herman Goldstein. Trying to get ahead on her task, the nurse changes the patient's diet from "Regular" to "Kosher." When the patient reaches the unit, the nurse discovers that the patient is Catholic even though his father is Jewish. The nurse is guilty of giving in to: A. illogical thinking. B. a bias. C. closed-mindedness. D. an erroneous assumption.

D. an erroneous assumption.

The nurse is caring for a patient who will be discharged home following surgical repair of a broken shoulder. The patient tells the nurse, "I don't have anyone at home who can help me cook my meals. Is there something you can do?" Demonstrating the adaptability of the nursing process, the nurse should: You Answered A. adjust the patient's care plan so that nursing goals can be met. B. consult the care provider about extending the patient's hospitalization. C. abandon the plan of care as not able to be done. D. contact the social worker about community services.

D. contact the social worker about community services.

The nurse makes the following entry on the patient's care plan: "Goal not met. Patient refuses to walk and states, 'I'm afraid of falling.'" The nurse should: A. ignore the patient's concern in evaluating goal attainment. B. document the patient's unwillingness to continue the plan of care. C. continue the plan of care as originally agreed upon. D. modify the care plan in response to the patient's condition and wishes.

D. modify the care plan in response to the patient's condition and wishes.

D. nurses must read recent literature and remain current in practice

In implementing research-based interventions, the nurse realizes that: A. implementation of evidence-based care is unique to the nursing profession. B. evidence-based practice is based entirely in nursing research. C. evidence-based care is focused on practices and not outcomes. D. nurses must read recent literature and remain current in practice

Which of the following MUST be done by an RN and not a nursing assistant? Select all that apply. Patient teaching Ambulation post-op day 1 Ambulation post-op day 4 Suctioning Normal skin care Admitting a patient from the post-anesthesia care unit

Patient teaching Ambulation post-op day 1 Suctioning Admitting a patient from the post-anesthesia care unit

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? Perform endotracheal intubation and initiate mechanical ventilation Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth Administer furosemide (Lasix) 100 mg IV push stat Call a code for respiratory arrest

Perform endotracheal intubation and initiate mechanical ventilation

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care? A. Perform postural drainage and chest physiotherapy every 4 hours B. Allow the patient to decide whether she needs aerosolized medications C. Place the patient in a private room to decrease the risk of further infection D. Plan activities to allow at least 8 hours of uninterrupted sleep

Perform postural drainage and chest physiotherapy every 4 hours

A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the nursing assistant (PCT)? Discuss weight-loss strategies such as diet and exercise with the patient Teach the patient how to set up the BiPAP machine before sleeping Remind the patient to sleep on his side instead of his back Administer modafinil (Provigil) to promote daytime wakefulness

Remind the patient to sleep on his side instead of his back

Which of the following CANNOT be delegated to a licensed practical nurse (LPN)? Select all that apply. Administering PO morphine Teaching a new patient proper nitroglycerin administration Admitting a patient from the post-anesthesia care unit Administering I.V. Lorazepam Dressing change of a patient, post-op day 5 Urinary catheterization

Teaching a new patient proper nitroglycerin administration Admitting a patient from the post-anesthesia care unit Administering I.V. Lorazepam

After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately? Heart rate of 98 beats/min Respiratory rate of 24 breaths/min Blood pressure of 168/90 mm Hg Tympanic temperature of 101.4 F (38.6 C)

Tympanic temperature of 101.4 F (38.6 C)

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the nursing assistant who will help the patient with activities of daily living? Select all that apply. Use a lift sheet when moving and positioning the patient in bed Use an electric razor when shaving the patient each day Use a soft-bristled toothbrush or tooth sponge for oral care Use a rectal thermometer to obtain a more accurate body temperature Be sure the patient's footwear has a firm sole when the patient ambulates

Use a lift sheet when moving and positioning the patient in bed Use an electric razor when shaving the patient each day Use a soft-bristled toothbrush or tooth sponge for oral care Be sure the patient's footwear has a firm sole when the patient ambulates

The nurse needs to know a patient's blood glucose before administering a medication. She asks the nursing assistant if she has been trained on fingersticks. The nursing assistant says she has not been officially trained, but has done it a number of times. What should the nurse do? Watch the nursing assistant perform a fingerstick to validate her ability Let the nursing assistant perform the fingerstick unsupervised Perform the fingerstick herself Ask another nurse to perform the fingerstick

Watch the nursing assistant perform a fingerstick to validate her ability