Adult Health Test 3: mix of chp 50, 16,17

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?

problem oriented

identification of a disease condition based on specific evaluation of signs and symptoms

medical diagnosis

clinical judgement about the patient in response to an actual or potential health problem

nursing diagnosis

A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food is not allowed in his diet owing to religious preferences. Based on this information, an appropriate nursing diagnostic statement is "imbalanced nutrition: less than body requirements related to.."

decreased oral intake

After completing a thorough assessment to formulate a patient database, the nurse should proceed to which step of the nursing process?

diagnosis

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What phrase is used to identify what the nurse is doing?

diagnostic reasoning

Which of these selections is an etiology for "acute pain" vs. a defining characteristic?-complain of pain 7 out of 10-disruption of tissue integrity-dull headache-discomfort while changing position

disruption of tissue integrity

A nurse is recovering a patient who received conscious sedation for cosmetic surgery. Which of the following is an advantage that conscious sedation has over general anesthesia?A) Loss of sensation at the surgical siteB) Reduction of fear and anxiety and need for assistance with airway patency and ventilationC) Amnesia and relief of painD) Monitoring in phase I recovery

Amnesia and relief of pain

Which of the following is an adverse side effect of inhalation anesthetics?A. Hypertension B. Increased intracranial pressure (ICP) C. Malignant hyperthermia D. Atrial tachycardia

C. Malignant Hyperthermia

Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?

"How many bowel movements a day have you had?"

A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?

"Nurses use evaluation to determine the effectiveness of nursing care."

A nurse assess that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of "Urinary retention?"

"do you feel like you need to use the bathroom"

A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use.1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma.2. Writes a diagnostic label of impaired gas exchange.3. Organizes data into meaningful clusters.4. Interprets information from patient.5. Writes an etiology.

1, 3, 4, 2, 5 Response Feedback: The correct order is:1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma.3. Organizes data into meaningful clusters.4. Interprets information from patient. 2. Writes a diagnostic label of impaired gas exchange. 5. Writes an etiology.

The nurse is revising the care plan. In which order will the nurse perform the tasks, beginning with the first step?1. Revise specific interventions.2. Revise the assessment column.3. Choose the evaluation method.4. Delete irrelevant nursing diagnoses.

2, 4, 1, 3

A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks?1. Revise nursing diagnosis.2. Reassess blood pressure reading.3. Retake blood pressure after medication.4. Administer new blood pressure medication.5. Change goal to blood pressure less than 140/90

2, 1, 5, 4, 3

A nurse records a client's VS before transferring him to a preanesthesia unit for an exploratory laparotomy. The client's temperature is 39C (102.2F) orally. Which of the following actions should the nurse take? A. Contact and inform the provider about the temp B. Transfer the client to the preanesthesia unit and notify the receiving nurse about the temperature. C. Administer 650mg of acetominophen and recheck the temperature in 1hr D. Apply a cooling blanket and recheck the cleint's temp in 30 min

A

Which of the following are a nurse's responsibilities regarding informed consent for a procedure? A. Ensure that the client signs the consent prior to administration of preoperative medications B. Provide additional literature about the procedure if the client has questions C. CLarify any points given by the provider about the procedure after the provider's explanation D. Document the client signing the consent form in the chartE. Delegate witnessing the client's signature on the consent form to an assigned assistive personnel.

A C D

The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all. A. The physical therapist didn't ambulate the client today B. The skin barrier's seal stays on in bed but loosens when the client stands. C. The client seemed to welcome having a "day off" from physical therapy D. The wound care nurse will see the client later today E. The client ate all the food on her lunch tray

A The physical therapist didn't ambulate the client today B The skin barrier's seal stays on in bed but loosens when the client stands. D The wound care nurse will see the client later today

After a surgical patient has been given preoperative sedatives, which safety precaution should a nurse take?A) Reinforce to the patient to remain in bed or on the stretcherB) Raise the side rails and keep the bed or stretcher in the high positionC) Determine if the patient has any allergies to latexD) Obtain informed consent immediately after sedative administration

A) Reinforce to the patient to remain in bed or on the stretcher

Hand-off communications that occur between the postanesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit should be done when a patient returns to the nursing unit. Select appropriate components of a safe and effective hand-off. (Select all that apply.)A) Vital signs, the type of anesthesia provided, blood loss, and level of consciousnessB) Uninterrupted time to review the recent pertinent events and ask questionsC) Verification of the patient using one identifier and the type of surgery performedD) Review of pertinent events occurring in the operating roomE) (OR) while at the nurses' station

A,B

The operating room (OR) and postanesthesia care unit (PACU) are high-risk environments for patients with a latex allergy. Which safety measures to prevent a latex reaction should the nurse implement? (Select all that apply.)A) Screening patients about food allergies known to have a cross-reactivity to latex such as kiwis and bananasB) Having a latex allergy cart available at all timesC) Communicating with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a latex-sensitive patient is identifiedD) Scheduling the latex-sensitive patient for the last operative case of the day

A,B,C

A patient is admitted through the emergency department for multisystem trauma following a motorcycle crash with multiple orthopedic injuries. He goes to surgery for repair of fractures. He is postoperative day 3 from an open reduction internal fixation of bilateral femur fractures and external fixator to his unstable pelvic fracture. Interventions that are necessary for prevention of venous thromboembolism in this high-risk postsurgical patient include: (Select all that apply.) A) Intermittent pneumatic compression stockings. B) Vitamin K therapy. C) Subcutaneous heparin or enoxaparin (Lovenox). D) Continuous heparin drip with a goal of an international normalized ratio (INR) 5 times higher than baseline.

A,C

A nurse is caring for a client who had a hysterectomy and resumed a regular diet earlier in the day. The client is now reporting nausea and has vomited once. Which of the following actions should the nurse take first?A. Assess for bowel sounds.B. Administer an antiemetic.C. Check the client's pain level. D. Place the client on NPO status.

A. Assess for bowel sounds

.You are caring for a patient after surgery who underwent a liver resection. His prothrombin time "PT" or an activated partial thromboplastin time "APTT" is greater than normal. He has low blood pressure; tachycardia; thready pulse; and cool, clammy, pale skin, and he is restless. You assess his surgical wound, and the dressing is saturated with blood. Which immediate interventions should you perform? (Select all that apply.) A) Notify the surgeon.B) Maintain intravenous (IV) fluid infusion and prepare to give volume replacement.C) Monitor the patient's vital signs every 15 minutes or more frequently until his condition stabilizes.D) Wean oxygen therapy.E) Provide comfort through bathing.

A. Notify the surgeon B. Maintain IV C. monitor vitals every 15 minutes

After an anesthesiologist delivers nitrous oxide with a face mask to a client, which of the following is the priority assessment? A. Oxygen saturation B. Blood pressure C. Heart rate D. Temperature

A. Oxygen Saturation

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?

Acute Pain

A patient presents to the emergency department following a motor vehicle crash that causes a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?

Acute pain

A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?

Ask about the chief concerns or problems.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make?

Ask the NAP to record the patient's vital signs before administering medications.

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations?

Ask the patient about the facial grimacing with movement.

While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?

Ask the patient about usual sleep patterns and the onset of having difficulty resting.

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 she 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 re-checked, and it has dropped even lower. In which phase of the nursing process did the nurse first make an error?

Assessment

You are caring for a 65-year-old patient 2 days after surgery and helping him walk down the hallway. The surgeon has ordered exercise as tolerated. Your assessment indicates that the patient's heart rate at baseline is 88. After walking approximately 30 yards down the hallway, the heart rate is 110. What should be your next action? A) Stop exercise immediately and have him sit in a nearby chair. B) Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise. C) Tell him that he needs to walk further to reach a heart rate of 120. D) Have him walk slower; he has reached his maximum.

B

You have been given the following postoperative patients to care for on your shift. Based on the information provided, which patient should you see first?A) A 75-year-old following hip replacement surgery who is complaining of moderate pain in the surgical site, with a heart rate of 92 B) A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of OSA. The pulse oximeter has been alarming and reading 85% C) A 36-year-old following bladder neck suspension who is 30 minutes late to receive her postoperative dose of antibiotic D) A 48-year-old following total knee replacement who needs help repositioning in bed

B

A nurse is working in the preoperative holding area and is assigned to care for a patient who is having a prosthetic aortic valve placed. The nurse inserts an intravenous (IV) line and obtains vital signs. The patient has a temperature of 39°C (102°F), heart rate of 120, blood pressure (BP) of 84/50, and an elevated white blood cell (WBC) count. The nurse immediately notifies the surgeon of the patient's vital signs because:A) They need to get the patient into the operating room (OR) quickly to start the surgery because of the low blood pressure.B) The surgery may need to be delayed to check the patient's WBC count and investigate the source of fever before surgery.C) The nurse anticipates the need for a fluid bolus to increase the patient's BP.D) The nurse anticipates an order for a sedative to help calm the patient and decrease the heart rate.

B Surgery may need to be delayed to check patients WBC and investigate source of fever

Obesity places patients at an increased surgical risk because of which of the following factors? (Select all that apply.)A) Risk for bleeding is increased.B) Ventilatory capacity is reduced.C) Fatty tissue has a poor blood supply.D) Metabolic demands are increased.

B) Ventilatory capacity is reduced. C) Fatty tissue has a poor blood supply.

A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all. A. Cover errors w/correction fluid, & write in the correct infoB. Put the date & time on all entriesC. Document objective data, leaving out opinionsD. Use as many abbreviations as possibleE. Wait until the end of the shift to document

B. Put the date & time on all entries C. Document objective data, leaving out opinion

A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation? Select all. A. Right clientB. Right supervision/evaluationC. Right direction/communicationD. Right timeE. Right circumstances

B. Right supervision/evaluation C. Right direction/communication E. right circumstances

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? Select All. A. The roommate is up independently. B. The client ambulates w/his slippers on over his antiembolic stockingsC. The client uses a front-wheeled walker when ambulatingD. The client had pain medication 30 min agoE. The client is allergic to codeineF. The client ate 50% of his breakfast this morning

B. The client ambulates w/his slippers on over his antiembolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 min ago

A nurse is preparing to care for a client in the surgical unit who will be receiving diazepam (Valium) IV. For which of the following should the nurse monitor this client? A. Status epilepticus B. Respiratory depression C. Malignant hyperthermia D. Acute facial dystoni

B. repertory depression

Which of the following preoperative client findings should be reported to a client's provider? A. Potassium level of 3.9 B. Sodium level of 145 C. Creatinine level of 2.8 D. Prothrombin time of 23 seconds E. Glucose level of 235 F. WBC count of 17,850

C D E F

A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report? A. The client's input & output for the shiftB. The client's BP from the previous dayC. A bone scan that is scheduled for todayD. The med routine from the med administration record

C. A bone scan that is scheduled for today

A young adult is having knee arthroscopy performed. After administration of midazolam (Versed), the nurse notices the client's blood pressure is 86/40 mm Hg, and his heart rate is 134/min. Which of the following should the nurse anticipate after informing the primary care provider of the client's vital signs?A. Administer naloxone hydrochloride (Narcan). B. Administer morphine sulfate. C. Give 500 mL 0.9% sodium chloride via an IV bolus. D. Stop the procedure.

C. Give 500 mL 0.9% sodium chloride via an IV bolus.

A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad caneC. Reapplying a condom catheter for a client who has urinary incontinenceD. Applying a sterile dressing to a pressure ulcer

C. Reapplying a condom catheter for a client who has urinary incontinence

A nurse is working in an ambulatory care setting and is ready to discharge a patient who is wheelchair dependent. The patient underwent dilation of an esophageal stricture. Her postanesthesia recovery score for ambulatory patients (PARSAP) score is 16. Her family is ready to go and eager to make the long road trip home. In determining if it is safe for the patient to be discharged at this time, the nurse should decide the following: A) The PARSAP score must be 18 or higher before being discharged .B) The patient's family is capable to care for her, and she understands her discharge instructions; thus the nurse proceeds with discharge. C) Since the patient hasn't been drinking much, the nurse is not concerned that she is unable to void and proceeds with discharge. D) Since the patient was admitted to the surgical center in a wheelchair, she can be discharged with a lower PARSAP score.

D

A 68 yr old client is undergoing an endoscopy, which will require moderate sedation. Which of the following findings in her history indicates the need for further assessment?A. Allergic to bee stingsB. GoutC. GI BleedD. COPD

D. COPD

An RN is making assignments for client care to a LPN at the beginning of the shift. Which of the following assignments should the LPN question?A. Assisting a client who is 24hr postop to use an incentive spirometerB. Collecting a clean-catch urine specimen from a client who was admitted on the previous shiftC. Providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump

D. Replacing the cartridge and tubing on a PCA pump

A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document?

Decreased Cardiac output related to myocardial contractibility

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?

Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

Diagnosis

A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?

Focus on the patient's presenting situation.

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Etiology

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?

Health Promotion

A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene?

Hemorrhage

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?

Impaired gas exchange related to alveolar-capillary membrane changes

Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia?

Impaired gas exchange related to alveolar-capillary membrane changes

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?

Impaired physical mobility related to incisional pain Nausea related to adverse effect of cancer medication

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan?

Impaired skin integrity

A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?

Nurse only speaks to patients daughter

A nurse is conducting a nursing health history. Which component will the nurse address?

Patient expectations

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

Patient will have one soft, formed bowel movement by end of shift.

A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?

Patient will increase activity level this shift.

Which method of data collection will the nurse use to establish a patient's database?

Performing a physical examination

A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign to this client? A. Charge nurseB. RNC. LPND. AP

RN

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage.

After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions?

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

A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?

The patient is apprehensive about discharge.

The following statements are on a patient's nursing care plan. Which statement will the nurse use as an outcome for a goal of care?

The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of the shift

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

a. Ambulating a patientb. Inserting a feeding tubec. Performing resuscitatione. Teaching about medications

Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)

a. Perform dressing changes twice a day as ordered.b. Teach the patient about signs and symptoms of infection.c. Instruct the family about how to perform dressing changes.e. Administer medications to control the patient's blood sugar as ordered.

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)

a. Rank all the patient's nursing diagnoses in order of priority. d. Consider time as an influencing factor. e. Utilize critical thinking.

A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?

abdominal distension

The four types of nursing diagnoses are

actual diagnoses, risk diagnoses, wellness diagnoses, and health promotion diagnoses.

For a student to avoid a data collection error, the student should:

assess the patient and, if unsure of the finding, ask a faculty member to assess the patient.

Which of these findings, when evaluating another nurse developing a plan of care, should the charge nurse recognize as a source of diagnostic error?a.Assigning diagnoses while completing the databaseb.Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous antibioticsc.Completing the interview before performing the physical examinationd.Documenting cultural and religious preferences

assigning diagnoses while completing the database

Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)

b. Determine whether outcomes or standards are met.d. Document results of goal achievement.e. Use self-reflection and correct error

A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)

c. Reposition a patient who is on bed rest.d. Teach a patient preoperative exercises.e. Transfer a patient to another hospital unit

A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?a.Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibioticsb.Completing an interview and physical examination before adding a nursing diagnosisc.Developing nursing diagnoses before completing the databased.Including cultural and religious preferences in the database

c.Developing nursing diagnoses before completing the database

John knows that a ______________ diagnosis is applied to vulnerable populations.

risk