Test 2 (Nursing Process) chapt: 4,5,6,7

The North American Nursing Diagnosis AssociationI (NANDA-I) list is revised and updated every:

2 years.

A nurse begins rounds on a medicalsurgical nursing unit. Review the following patients on her assignment. Prioritize the order in which the patients should be assessed, based on their descriptions. (Separate letters with a comma and space as follows: A, B, C, D.)

A. A 22-year-old patient who is awakening from neck surgery. D. A 35-year-old patient admitted for an injury to his left femoral artery, which required surgical repair 8 hours ago following an ice-skating accident. C. A 44-year-old patient with dehydration from vomiting and diarrhea, who was admitted 3 days ago and who has an IV infusion of fluids. B. An 82-year-old patient who is blind and needs discharge instructions.

The agency-wide process that takes into consideration nursing audits and compliance to standards of every department is the _____________.

Outcome Based Quality Improvement

A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical chart to take, because it is her personal property. An appropriate response would be:

You are entitled to the information in your chart, but the chart is the property of the hospital. I will see about having a copy made for you.

The nurse performing an admission interview on an elderly person should:

allow more time for a response to questions.

A nurse will arrive at a nursing diagnosis through the nursing process step of:

assessment.

The nurse takes into consideration that the difference between a sign and a symptom is that a sign is:

can be verified by examination.

A nursing diagnosis consists of:

diagnostic labels formulated by the North American Nursing Diagnosis AssociationInternational (NANDA-I).

Standardized Nursing Care Plans can:

have items altered or deleted.

The major goal of the admission interview (usually performed by the RN) is to:

identify the patients major complaints.

The nurse clarifies that nursing orders are also called:

interventions.

A student nurse can begin to develop critical thinking skills by means of:

listening attentively and focusing on the speakers words and meaning.

A nurse understands that the physicians directives for patient care are also referred to as the:

physicians orders.

In assigning tasks to the nursing assistant, the nurse could appropriately select:

range-of-motion exercises to lower limbs.

Before performing a catheterization, the inexperienced nurse should:

review the agencys procedure manual for the accepted way of performing the procedure.

The nurse should make a point when closing the initial interview to: (Select all that apply.)

summarize the problems discussed. thank the patient for his or her time.

Standards of care are set by: (Select all that apply.)

the states nurse practice act. professional medical association standards. the facilitys policies and procedures.

The nurse uses the flow sheet in patient care documentation primarily:

to track routine assessments, treatments, and frequently given care.

Preparing a patient for a diagnostic test, and telling the patient what to expect during and after the test, is considered:

an independent nursing action.

The general rule is that the initial care plan for a patient is:

developed by an RN in an acute care setting.

The effect of using a scientific problem-solving approach in nursing care will cause decision making to be:

improved nursing care outcomes.

Conclusions that have been made based on observed data are __________.

inferences Inferences are conclusions made based on observed data.

The Quality and Safety Education for Nurses (QSEN) project has identified the most important pre-licensing skills for nurses as:

informatics.

A nursing care plan consists of:

nursing orders for individualized interventions to assist the patient to meet expected outcomes.

An elderly patient with a medical diagnosis of chronic lung disease has developed pneumonia. She is coughing frequently and expectorating thick, sticky secretions. She is very short of breath, even with oxygen running, and she is exhausted and says she cant breathe. Based on this information, an appropriately worded nursing diagnosis for this patient is

Airway clearance, ineffective, related to lung secretions as evidenced by cough and shortness of breath.

Which of the following items could be the responsibility of the LPN/LVN for a patients plan of care? (Select all that apply.)

Collect data. Perform nursing interventions. Assist the RN with evaluation of the patients response to nursing interventions.

Appropriate nursing roles in the initial assessment would include: (Select all that apply.)

LPN obtains the vital signs of a new patient. RN performs a complete physical assessment. RN reviews the patients chart for past medical/surgical history. LVN contributes ongoing assessments.

In the collaborative process of delivering care based on the nursing process, the responsibility of the LPN/LVN is to:

collect data of health status.

When a nurse prioritizes the patient care, consideration is given to:

considering situations that may result in an alteration of health.

The nurse evaluates that the patient has met the outcome of feeding himself independently. The nurse should:

document the ability to self-feed and mark the nursing diagnosis as resolved.

Activities considered to be aspects of the implementation step of the nursing process are: (Select all that apply.)

documentation of care given. assembly of supplies.

A nurse enters a notation in a patients chart but then discovers that the notation was made in the wrong chart. The nurse correctly:

draws a single line through the notation so that it is still readable and writes mistaken entry, his signature, and the date and time.

In an acute care facility, a nursing care plan is usually reviewed and updated:

every 24 hours.

During the assessment phase of the nursing process, the nurse

gathers, organizes, and documents data in a logical database.

The nurse designs the goals for patients in long-term facilities to be:

long-term.

The nurse understands that a face sheet contains information pertaining to:

patient data, including patients name, address, phone number, insurance company, and admitting diagnosis.

During morning care in a skilled nursing facility, the student nurse notices that the patient who is at risk for impaired skin integrity has developed a small open area on his sacrum. To best address this situation, the student would first:

position the patient to lie on his side, document it, and inform the head nurse.

If a patient has several nursing diagnoses, the nurse will first:

prioritize the nursing problems according to Maslows hierarchy of needs.

The nurse is assessing a patient who just returned from a bowel resection 1 hour ago. The nurse notes a dressing over the suture line that is wet with sero-sanguineous drainage. The nurse should initially:

reinforce the wet dressing and document.

When the patient complains of nausea and dizziness, the nurse recognizes these complaints as _______ data.

subjective

Constant nursing assessments and evaluations of the patient will most likely result in:

the nursing care plan changing to reflect appropriate priorities.

Aside from the information obtained from the patient (primary source) in the admission interview, the nurse will also access: (Select all that apply.)

the patients family. the admission note. the physicians history and physical. an observation of the patient for non-verbal clues.

The purpose of the Nursing Outcomes Classification (NOC) is to: (Select all that apply.)

validate classification by field test. identify labels. provide language labels for desired outcomes. identify patient outcomes and indicators.

A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is:

violating the confidentiality of the patients record.

Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?

4 cm reddened area over sacrum. Skin intact, warm, and dry.

The nurse caring for a group of patients would show cultural sensitivity to assign an older male nursing assistant to the care of a:

55-year-old Japanese man with irritable bowel syndrome.

The nursing diagnoses that has the highest priority is:

Airway clearance, ineffective, related to neuromuscular disorder as evidenced by choking and coughing while eating.

A nurse is caring for a patient with a medical diagnosis of right lower lobe pneumonia. The patient is expectorating thick green mucus, has an oxygen saturation level of 90%, and has audible crackles in the base of the right lung. An appropriate nursing diagnosis for this patient is:

Airway clearance, ineffective, related to retained secretions as evidenced by expectoration of thick green mucus, oxygen saturation level of 90%, and audible crackles in the base of the right lung.

A nurse is caring for a patient with a nursing diagnosis of impaired physical mobility related to neurologic impairment and muscular weakness. Appropriate interventions for this patient would include which of the following? (Select all that apply.)

Assist with range-of-motion exercises every 4 hours and as needed. Instruct patient to call for assistance when needing to get out of bed. Teach about exercises that will strengthen muscles while lying in bed. Ambulate with physical therapy assistance at least three times a day.

Place the steps of the problem-solving approach in the appropriate order. (Separate letters with a comma and space as follows: A, B, C, D, E.)

D. Identify the problem. C. Consider all possible alternatives as the solution to the problem. E. Examine possible outcomes of each alternative. A. Predict the likelihood of each outcome occurring. B. Choose the alternative with the best chance of success.

An example of a structured format for gathering data that aids in forming a database is:

Gordons 11 Health Patterns.

At the 7:00 AM change-of-shift report, the nurse receives the report that patient A had a sleepless night related to pain and just fell asleep after an increased pain medication administration one-half hour ago. Patient B, who is scheduled for surgery at 8:30 AM, is also sleeping. How would an organized nurse plan the early morning activities?

Prep patient B now; allow patient A to sleep.

Which examples of documentation would be most informative to transcribe to the patients medical record?

Patient consumed two slices of bread and a cup of coffee at breakfast.

The statements that are correctly stated as expected outcomes are: (Select all that apply.)

Patient will be able to ambulate using a walker independently within 3 days. Patient will perform active range of motion (ROM) of her upper extremities independently every 4 hours.

A clinic nurse is documenting in a patient chart about the pain that brought the patient to seek medical attention. The best description is:

Peri-umbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids.

A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says to the nurse, I dont want to have you draw any more blood for those useless tests. When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:

Refuses to have blood drawn; says tests are useless. Doctor notified.

In an agency that uses specific protocols (Standard Procedures) and charting by exception, an advantage compared with using traditional (narrative or problem-oriented) charting is that charting by exception:

highlights abnormal data and patient trends.

When the nurse charts in narrative or source-oriented format about the patients condition and the nursing care provided, it is appropriate for him to record:

To x-ray by wheelchair @ 10:30 AM IV infusing in left arm.

In a chart for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives, the nurse charts Subjective: denies itching. Happy with improvement in skin. Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm, dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge. This type of charting is an example of:

a problem-oriented medical record (POMR).

The nurse giving a patient a back massage is performing an intervention considered to be a(n) _____ nursing action.

independent

The nurse documents interventions periodically during the shift in nurses notes primarily to:

indicate that the nursing care plan has been implemented.

A nurse begins the shift caring for a patient who has just returned from the recovery room after surgery. It is most important to document:

an initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift.

The nurse who uses the nursing process will:

approach the patients disorder in a step-by-step method.

A patient with visual impairment is identified as at risk for falls related to blindness. An appropriate intervention would be to:

arrange furnishings in room to provide clear pathways and orient the patient to these.

After the admission assessment is completed, on subsequent shifts or days, the nurse:

assesses the patient briefly in the first hour of the shift.

When a resident in the nursing home complains of constipation, the nurse performs a digital rectal examination and finds a hard fecal mass. This is an example of:

assessment

The order in which the nursing process is approached is:

assessment, nursing diagnosis, planning, implementation, evaluation.

Once the nursing plan has been initiated, the nursing care plan will:

change as the patients condition changes.

The activity that is implementation in nursing care is:

changing the patients surgical dressing.

The nurse coming on duty has received a report that an IV of 1000 ml of 5% glucose in 0.9% normal saline is running at a rate of 50 ml an hour to be followed by another 1000 ml to be run at the same rate. The reporting nurse states that the second IV should be hung at 9:00 AM. The prudent nurse should: (Select all that apply.)

check to label on the present IV. confirm the flow rate. check the order for the IVs.

Critical thinking is considered to be the keystone and foundation of the development of _________.

clinical judgment

The seven domains of the Nursing Interventions Classification (NIC) taxonomy include: (Select all that apply.)

community. health system. safety. behavioral.

An emergency room nurse will give first priority to the patient with the most critical need, which is the patient who:

complains of severe chest pain.

The tasks of synthesizing data and linking nursing interventions with patient health problems are enhanced by the process of ________.

concept mapping

When the nurse constructs a nursing approach after careful judgment and sound reasoning, the nurse has used a system of __________.

critical thinking

The nurse administering a medication to a patient is performing an intervention that is a(n) _____ nursing action.

dependent

Descriptions of the activities involved in the nursing diagnosis step of the nursing process are: (Select all that apply.)

determination of potential health problems. clustering of related assessments.

The purpose of the evaluation step of the nursing process is to: (Select all that apply.)

determine if outcomes have been reached and the goals are met. compare actual outcomes with expected outcomes. confirm that nursing interventions are effective.

The nurse compares actual nursing outcomes to the expected nursing outcomes in order to:

determine if progress is made or to determine if revisions are needed.

A patient has a nursing diagnosis of Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30-pounds over the last 6 months. An appropriate short-term goal for this patient is to:

eat 50% of six small meals each day by the end of 1 week.

Advantages of source-oriented or narrative charting include all of the following except that it:

encourages documentation of normal and abnormal findings.

The nurse is aware that the nursing audit is a valuable process used to:

evaluate whether nursing care for a group of patients meets the standards of care in that facility.

When the nurse checks to see whether a patient has had relief 45 minutes after administering pain medication, the nurse is performing a(n):

evaluation.

A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by disruption of skin surface has the following nursing documentation: Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing. Verbalizes understanding of wound care and ability to manage at home. Wound healing without complication. This documentation is:

evidence of the use of the nursing process.

Nurses design interventions that are appropriate for a patient that are:

expected to help the patient meet the goals most quickly.

When a patient states, I cant walk very well, the first problem-solving step would be to:

find out what the problem is, such as weakness or poor balance.

The nurse completing morning assessments on a patient who is sitting up in bed is told by the patient, Im having trouble breathingI cant seem to get enough air. The best nursing response is to:

finish the vital signs for the assigned patients, and then notify the charge nurse.

If an agency is using computer-assisted charting, the nurse is responsible for:

guarding the confidentiality of the patient record by not leaving the patient screen on if he leaves the terminal.

The participants of the planning stage of the nursing process during which the health goals are defined include the:

health team, the patient, and the patients family.

The nurse with a patient who complains of severe pain documents every 15 minutes about the steps taken to try to relieve the pain (without success). The nurse also documents the time and content of two calls made to the patients physician requesting that the physician examine the patient for unexpected complications. This documentation by the nurse is likely to:

justify insurance reimbursement for an extended duration of hospitalization for the patient.

Prior to the nurse implementing a nursing procedure for a patient, the nurse should initially:

mentally review the procedure.

A nurse tells her neighbor personal information about a hospitalized patient. Telling her neighbor about this indicates that the:

nurse has violated the confidentiality of the patient by discussing personal information about the patient with his neighbor.

In a skilled nursing facility, if all of the following are available, the best way for the new nurse to obtain current information about the needs and abilities of his patients would be to use the:

nursing Kardex.

When an agency is using a clinical pathway/care map protocol of health care provision, there is no need for a(n) ________________.

nursing care plan

An example of an appropriately worded nursing goal or outcome for the nursing diagnosis of Risk for falls related to weakness would be:

patient will call for assistance when ambulating for the next week.

A nursing diagnosis identifies: (Select all that apply.)

patients response to illness. related signs and symptoms. causative factors. potential risk for health problems.

The nurse understands that an expected outcome should be: (Select all that apply.)

realistic. attainable. within a defined time. included after patient collaboration.

The nurse explains that a multidisciplinary step-by-step approach to patient care is:

referred to as a clinical pathway and is used instead of a nursing care plan.

The nurse is aware that one of the time-flexible tasks to be accomplished would be:

taking the patients vital signs once a day.

A review of a patients nursing care plan before beginning care allows the nurse to:

use critical thinking skills to organize care for the patient.