Chapter 36 and 47 Questions

Trial and error

The nurse is caring for a patient who is having back discomfort. The nurse helps the patient change position several times until comfortable. Which process is defined by this action? a. Trial and error b. The nursing process c. Intuition d. Clinical decision making

Administer the patient's medication at 8:45 a.m.

The nurse is caring for a patient who is scheduled to have a chest x-ray at 9:00 a.m. and will be off the unit. The patient is also due to have medication at 9:00 a.m. Which action by the nurse is most appropriate? a. Administer the patient's medication at the start of shift. b. Wait to administer the medication at the next dosage time. c. Administer the medication after the patient returns from x-ray. d. Administer the patient's medication at 8:45 a.m.

Intuition

The nurse is caring for a patient who was admitted with abdominal pain. The patient's complete blood count (CBC) is normal, but the nurse is still concerned about the patient having a gastrointestinal bleed and monitors the patient closely. Which cognitive skill is the nurse displaying? a. Reasoning b. Intuition c. Inquiry d. Reflection

Proficient

The nurse is caring for a patient with a history of diabetes mellitus. The nurse notices an upward trend to the patient's daily fasting serum blood glucose and notifies the patient's healthcare provider. Which level best describes this nurse according to Benner's skill acquisition model? a. Novice b. Proficient c. Advanced beginner d. Competent

Use colored pencils or markers.

The nurse is creating a concept map to guide a plan of care for a patient with multiple health problems. The nurse is using paper and pencil to create the map because the nurse is not comfortable with using the computer for this activity. How could the nurse easily improve the readability of the map? a. Find a software program that the nurse is comfortable with. b. Use a concept-map template. c. Use colored pencils or markers. d. Make sure to match colors and shapes and coordinate patterns

Develop a legend for the concept map.

The nurse is creating a patient concept map for a simulation scenario. Which should the nurse do first when creating the concept map? a. Gather and sort significant clusters of assessment data. b. Look at the assessment data, including both subjective and objective data. c. Put a shape with patient information and priority medical diagnosis in the middle of the paper. d. Develop a legend for the concept map.

Nursing plan of care for each patient

The nurse is delegating assignments to unlicensed assistive personnel (UAPs) on a medical-surgical unit. When making assignments, which is the best resource for the nurse to use as a guide? a. Medical diagnosis of each patient b. Nursing plan of care for each patient c. Ages of the patients d. Functional status of each patient

Different colored sticky notes

The nurse is working on a concept map for a patient with multiple health problems. Which noncomputerized method should the nurse consider that would most easily allow the nurse to move data around until the concept map is finished? a. Pencil and paper b. Different colored sticky notes c. Different colored ink pens and paper d. Formatted concept-map template

Assisting in the ambulation of a postoperative patient

The nurse on a medical-surgical unit has finished receiving the report on five assigned patients for the day. Which nursing intervention should the nurse consider an acute intervention when organizing the day? a. Assisting in the ambulation of a postoperative patient b. Teaching a patient and family how to care for an indwelling urinary catheter c. Sitting with a patient who is anxious about an upcoming procedure d. Completing an activity of daily living (ADL) assessment on a patient who is being transferred to a long-term care facility

Justice and fairness

A nurse new to the emergency department is struggling with triaging patients and assigning priority for care because many of the individuals who present seem to have equally significant problems. Which ethical principles should the nurse use as guides when setting priorities? a. Integrity and respect b. Justice and fairness c. Autonomy and accountability d. Fidelity and beneficence

"I'll get the pain medication first because the pain level is so high, and I'll get another staff member to refill the water pitcher."

A patient admitted for palliative care secondary to a recent diagnosis of pancreatic cancer asks the nurse for medication for pain because the pain is now a 9 on a 10-point scale. The family of the patient also asks if the nurse can make sure to fill the patient's water pitcher. Which response by the nurse would best help the family to understand the prioritization of the current needs? a. "The medications are not near the water station. Is it okay if I bring the water later?" b. "Right now, I'm just worried about getting the pain under control." c. "I'll get the pain medication first because the pain level is so high, and I'll get another staff member to refill the water pitcher." d. "I'll see what I can do; I'll be back as soon as I can."

Planning to talk with the patient about the patient's care needs, priorities, and preferences

A patient is admitted for dehydration. During morning care, the patient becomes upset when the breakfast tray features items that the patient does not eat. The patient tells a family member that the staff must not think the patient is important. Which should be the immediate nursing intervention to improve patient care? a. Identifying the easiest task to complete for the patient and doing this first b. Explaining to the patient that the patient's care issues are not life-threatening and can be delayed c. Discussing the importance of other patients' treatments being of greater priority d. Planning to talk with the patient about the patient's care needs, priorities, and preferences

"I will request that the dialysis staff schedule you for after completion of your morning program if possible."

A patient is hospitalized for the initiation of renal dialysis. The patient shares with the nurse that the patient likes to watch the morning news to start the day and would really like it if the dialysis did not interfere with that routine. Which statement would be the nurse's best response to this request? a. "I can try, but schedules are very tight, so it is not likely that it will happen." b. "Although I know your show is important to you, the need for dialysis is greater; when you get back home, you can watch your show." c. "I am sorry, but it truly is not possible to accommodate this request. Maybe your family can record it for you." d. "I will request that the dialysis staff schedule you for after completion of your morning program if possible."

Administering medications based on vital signs taken during the previous shift

After shift handoff, the nurse prioritizes care for the assigned patients. Which action is a common pitfall when prioritizing patient care? a. Involving the patient during the care-planning process b. Completing tasks based on level of difficulty c. Being cognizant of time when completing tasks d. Administering medications based on vital signs taken during the previous shift

Awareness of self-limits

The nurse is caring for a patient with an electrolyte disturbance. The healthcare provider asks the nurse to draw an arterial blood gas (ABG), but the nurse has never performed the procedure and asks a more senior nurse to assist. Which critical thinking attitude is exemplified by the nurse's action? a. Perseverance b. Awareness of self-limits c. Differentiating fact from fiction d. Approaching situations objectively

Assessing neurologic status frequently

The nurse is caring for a patient with increased intracranial pressure. Which is a priority nursing intervention? a. Monitoring oxygenation status b. Assessing neurologic status frequently c. Checking for bowel and bladder distention d. Spacing nursing care to allow for rest periods

The parents must provide consent.

The nurse is caring for a teenager who requires surgery to repair a broken femur after a motor vehicle crash. Which statement about patient consent is correct? a. The parents must provide consent. b. The teenager must sign the consent form. c. The parents must provide consent, and the teen must sign an assent form. d. The teenager must sign the consent form, and the parents must also provide assent.

Creativity

The nurse is caring for a toddler who appears frightened by the nurse. To make the child more at ease, the nurse gives the toddler a disposable tape measure to play with. Which critical thinking concept is the nurse displaying? a. Concreteness b. Confidence c. Independence d. Creativity

Reflecting

The nurse is caring for a young woman who is receiving antibiotics for a urinary tract infection. The patient returns to the clinic complaining of continued burning urination 4 days after starting the medication. The nurse looks at the patient's chart and notices that a urine culture was never performed. Which feature of Tanner's clinical judgment model is displayed here? a. Responding b. Interpreting c. Noticing d. Reflecting

The patient complains of shortness of breath when walking from the bed to the bathroom.

The nurse is caring for several patients during a shift. Which data collected during a nursing assessment should be a priority for care? a. The patient complains of shortness of breath when walking from the bed to the bathroom. b. The patient has a blood pressure of 96/54 mmHg, heart rate of 70 beats/min, respiration rate of 20 breaths/min, and temperature of 97.6°F. c. The patient begins coughing after 6 minutes of walking. d. The patient has an oxygen saturation of 94%.

A patient with stroke symptoms

The nurse is caring for several patients in the emergency department. Which patient should the nurse prioritize for care using the urgency factor? a. A patient with a fractured femur b. A patient with stroke symptoms c. A patient with sharp, continuous pain radiating from the kidney area d. A young child with a possible arm fracture

Patient-specific clinical pathway

The nurse is completing the admission process for a patient scheduled for a radical prostatectomy. Which should the nurse provide to the patient to help him best understand what to expect in terms of time frames, actions, and results related to this procedure? a. Concept map b. Patient-specific clinical pathway c. Clinical pathway d. Patient education pamphlet

Imminent death

The nurse is conducting triage in a mental health facility. A family member brings in a patient for suspected overdose. The patient's breathing is very slow and shallow, and the patient is not responding to the nurse's questions. The nurse has several other patients awaiting triage. Which level of urgency in nursing intervention should the nurse prioritize? a. Critical b. Acute c. Imminent death d. Non Acute

Obtain a dietary consult for the patient.

The nurse is creating a column plan of care. Which information should the nurse place in the intervention column for a diabetic patient with a slow-healing foot wound? a. Patient will list three high-protein foods to include in the diet by the end of hospitalization. b. Patient named five foods high in protein prior to discharge. c. Patient has a ½-inch by ½-inch open wound on the dorsal aspect of the right foot. d. Obtain a dietary consult for the patient.

Determine the priority nursing diagnosis for each cluster; use lines to connect them to the clusters.

The nurse is creating a concept map for a patient with multiple health problems. After creating clusters of assessment data, which should the nurse complete next to prioritize patient needs? a. Determine the priority nursing diagnosis for each cluster; use lines to connect them to the clusters. b. Develop appropriate goals and outcomes for care; use lines to connect these to the relevant clusters. c. Develop priority nursing interventions; use lines to connect them to the relevant nursing diagnoses. d. Determine goals and outcomes that can be achieved through nursing care; use lines to connect these to relevant nursing diagnoses.

Following the sequence of the nursing process

The nurse is creating a concept map for a patient. Which guideline should be followed when preparing a concept map? a. Individualizing the care by using checklists and blank lines b. Following the sequence of the nursing process c. Highlighting medical treatments provided by other providers d. Including the rationales for each nursing intervention

At the beginning of the concept-map development

The nurse is creating a legend for a concept map. At which point in the development of the concept map should this activity occur? a. At the end when the concept map is complete b. At the beginning of the concept-map development c. When the number of necessary data clusters has been determined d. After data clusters, nursing diagnoses, and nursing interventions have been created

Assessment, nursing diagnoses, goals/desired outcomes, nursing interventions, evaluation

The nurse is creating a nursing plan of care for a patient admitted for surgery. Which headings should the nurse use as the pre- and postoperative nursing plan of care is created? a. Assessment, nursing diagnoses, goals/desired outcomes, nursing interventions, evaluation b. List of medications, nursing diagnoses, goals/outcomes, nursing interventions, evaluation c. Demographic information, assessment data, nursing diagnoses, nursing interventions, outcomes d. Medical and nursing diagnoses, goals/outcomes, nursing interventions, evaluation

Prioritize three to five nursing diagnoses.

The nurse is creating a plan of care for a patient with complex health problems, including sepsis. Which action should the nurse take to focus nursing care and support the best patient outcomes? a. Create two to three general categories of nursing diagnosis. b. Focus nursing diagnoses only on those issues caused by the sepsis. c. List all applicable nursing diagnoses, highlighting those that have highest priority. d. Prioritize three to five nursing diagnoses.

"The three-column plan has no assessment column and combines goals/desired outcomes and evaluation into one column."

The nurse is describing the three-column plan of care. Which description by the nurse provides an accurate description? a. "The three-column plan has no assessment column and combines goals/desired outcomes and evaluation into one column." b. "The three-column plan only has nursing diagnosis, nursing interventions, and goals/desired outcomes." c. "The three-column plan combines assessment with nursing diagnosis and combines goals/desired outcomes with evaluation." d. "In the three-column plan, nursing diagnosis and evaluation are stand-alone columns, whereas interventions and goals/desired outcomes are combined."

Planning

The nurse is developing a plan of care for a patient admitted to the hospital for pneumonia. Which phase of the nursing process will the nurse use to develop a. Assessment b. Implementation c. Planning d. Nursing diagnosis

"A nursing diagnosis is based on clinical judgment that is derived from assessment data."

The nurse is explaining how to develop an appropriate nursing diagnosis. Which participant statement indicates an appropriate understanding? a. "A nursing diagnosis is based on clinical judgment that is derived from assessment data." b. "A nursing diagnosis is developed after the nurse evaluates the interventions provided." c. "A nursing diagnosis is derived after the nurse develops the plan of care for the patient." d. "A nursing diagnosis is determined by the medical diagnosis and current patient needs."

Each column represents a day of care.

The nurse is using a clinical pathway to provide care to a patient hospitalized with pneumonia. While reviewing the clinical pathway, the nurse would note that the columns organize care in which manner? a. Each column represent a different health discipline. b. Each column represents a different nursing diagnosis. c. Each column represents an expected patient response. d. Each column represents a day of care.

Nursing interventions

The nurse is working for a facility that requires the use of a column framework for planning care. Information in which column of the plan of care is best derived from and supported by research evidence? a. Nursing interventions b. Nursing diagnosis c. Goals/desired outcomes d. Evaluation

Inductive reasoning

The nurse is working on the oncology floor of the hospital and notes that many of the patients request internet access so that they can communicate with loved ones more easily. Using this information, the nurse obtains a grant to purchase several laptops for the patients to share. Which type of reasoning did the nurse use to develop this protocol? a. Clinical reasoning b. Careful reasoning c. Deductive reasoning d. Inductive reasoning

"I should have remembered to check the patient's wristband even though I've been taking care of this patient for several days."

The nurse made a medication error while caring for a patient. Which statement by the nurse indicates that the nurse is interpreting the situation using guided reflection? a. "I should have remembered to check the patient's wristband even though I've been taking care of this patient for several days." b. "I was so busy giving medication that I misread the order and gave the wrong one to the wrong patient." c. "I had to tell the patient and doctor that I gave the wrong medication. It was very embarrassing." d. "The medication didn't harm the patient, but I need to be more careful whenever I give medication."

Benner's skill acquisition model

The nurse manager is looking at models of clinical judgment to use as an employee assessment tool. The nurse manager wishes to use a model that can evaluate clinical competence in the workplace. Which is best suited for the job? a. Tanner's clinical judgment model b. Guided reflection c. Benner's skill acquisition model d. Lasater's clinical judgment rubric

Focused on a specific patient problem when planning care

The nurse manager is preparing an annual performance appraisal for a staff nurse who has worked on a medical-surgical care area for 2 years. The manager determines that the staff nurse's level of proficiency is competent. Which action by the staff nurse prompts the manager to make this decision? a. Determined how a new medication would impact a patient's other health problems b. Focused on a specific patient problem when planning care c. Referred to the procedure manual to change the dressing at an intravenous (IV) site d. Waited for direction from charge nurse before providing care

Asking the nurse if any tasks can be delegated to others so that the nurse can take a break

The nurse manager notes that one of the nurses is 6 hours into the shift and has not had a break due to receiving two admissions. When the nurse manager asks the nurse how things are going, the nurse tersely responds, "Fine, just busy." Which action by the nurse manager would best address this situation? a. Telling the nurse to immediately take a break and finish up the admission paperwork after the break b. Asking the nurse if any tasks can be delegated to others so that the nurse can take a break c. Providing reassurance that the nurse will not receive any further admissions so that the nurse can catch up d. Asking the nurse to meet prior to the next assigned shift to discuss ways to better prioritize time management so that breaks can be taken

The patient reports mild dyspnea, diaphoresis, and restlessness.

The nurse notices changes in the condition of the patient who is second-day postoperative after a coronary artery bypass graph. Which changes should receive priority by the nurse for immediate sharing with other members of the healthcare team? a. The patient desires to prepare advance directives. b. The patient's total serum cholesterol level is 376 mg/dL. c. The patient reports mild dyspnea, diaphoresis, and restlessness. d. The patient verbalizes feelings of hopelessness in relation to cardiac status.

Asking the UAP to finish the wound dressing and immediately assessing the patient with chest pain

The nurse on a medical-surgical unit has organized care for the assigned four patients. As the nurse prepares to complete a simple wound-care dressing on a patient, the unlicensed assistive personnel (UAP) informs the nurse that another patient is experiencing chest pain. Which action by the nurse would be most appropriate at this time? a. Asking the UAP to quickly send another nurse down to the room of the patient with chest pain b. Asking the patient with the wound dressing in progress to stay in position until the nurse can return after assessing the patient with chest pain c. Asking the UAP to finish the wound dressing and immediately assessing the patient with chest pain d. Asking the UAP to activate the rapid response team

The patient with difficulty breathing requiring oxygenation

The nurse who is working in the emergency department receives multiple patients. Which patient requires priority nursing care? a. The patient with atelectasis requiring thoracentesis b. The patient with a laceration to the lower extremity requiring sutures c. The patient with a distended bladder and accompanying pain requiring catheterization d. The patient with difficulty breathing requiring oxygenation

Intuition

The nurse with 15 years of obstetric experience is caring for a patient in labor who is reporting extreme pain. The nurse knows that the patient is likely getting very close to delivery but asks the provider to come and evaluate the patient. Which decision-making process is reflected in this situation? a. Trial and error b. Intuition c. The scientific method d. The nursing process

Awareness of self-limits

The nurse working in the intensive care unit (ICU) has decided to attend a professional critical care conference. Which critical thinking attitude is exemplified by the nurse's actions? a. Awareness of self-limits b. Integrity c. Confidence d. Independence

A patient 2 days post-stroke, with vital signs within normal limits, has begun the rehabilitation program.

The nurse works on a cardiopulmonary stepdown unit that uses standardized care plans for patients. In which patient scenario would a standardized plan of care be most appropriate? a. A patient 1 week post-stroke, tearful and depressed, is not participating actively in rehabilitation efforts and is refusing to eat. b. The family of a patient with chronic obstructive pulmonary disease (COPD) exacerbation indicates they are tired of dealing with the patient's issues because the patient refuses to quit smoking. c. A patient 2 days post-stroke, with vital signs within normal limits, has begun the rehabilitation program. d. A patient with recently diagnosed inoperable lung cancer has been homeless for the past 7 years.

Asking if the child would like to have the scheduled snack before or after going for an x-ray

Which action by the nurse indicates support for a preschooler's decision-making ability? a. Inviting the child to the interdisciplinary meeting b. Showing the child the materials that will be used to stitch up the wound in the child's knee c. Asking if the child would like to have the scheduled snack before or after going for an x-ray d. Soothing the child by rocking the child until calm

Assess pulse, respiratory rate, and blood pressure.

Which action should the nurse perform immediately upon the patient's arrival? a. Insert a Foley catheter. b. Insert two large-bore intravenous (IV) catheters for fluid replacement. c. Obtain a complete medical history from those accompanying the patient. d. Assess pulse, respiratory rate, and blood pressure.

The nurse administers an intravenous (IV) narcotic instead of an oral narcotic.

Which clinical situation best exemplifies the nurse who is choosing between alternatives when making a clinical decision? a. The nurse administers an intravenous (IV) narcotic instead of an oral narcotic. b. The nurse changes the patient's position numerous times until the patient appears in less pain. c. The nurse has a "gut reaction" to the patient's pain and calls the patient's physician. d. The nurse determines that the patient's nursing diagnosis is Pain, Acute.

Blood draw for vancomycin trough

Which nursing intervention would require priority based on a time constraint? a. Foley catheter change b. Wound dressing change c. Blood draw for vancomycin trough d. Admission assessment for new hospice patient

Concept map

Which process can be used to visualize relationships among clinical data and help to prioritize meeting patient needs? a. Column plan of care b. Standardized plan of care c. Clinical pathway d. Concept map

Inappropriate delegation

While the nurse is caring for a patient who had a fall, a monitor alarm for an intravenous (IV) line goes off in the adjacent room. The nurse asks the unlicensed assistive personnel (UAP) to go to that room and slow the rate of the IV down until the current patient's care is finished. Which common pitfall has occurred based on the action taken? a. Inappropriate delegation b. Incomplete assessment c. Poor time management d. Failure to do periodic reassessments

Scheduling decision

The nurse decides to take vital signs and draw morning blood work before the patient's family comes to visit. Which type of decision does the nurse's action reflect? a. Value decision b. Time-management decision c. Scheduling decision d. Priority decision

DRGs determine the number of preset days allowed for care for patients with that specific medical diagnosis.

During a discussion of clinical pathways with a recent nursing graduate, the nurse preceptor mentions the use of diagnosis-related groups (DRGs) as the basis for clinical pathways. The new nurse asks what the DRGs are used for. Which information should the nurse preceptor provide to the new nurse? a. DRGs determine the number of preset days allowed for care for patients with that specific medical diagnosis. b. DRGs are used to determine the detailed nursing interventions to include in the clinical pathway. c. DRGs are used to group conditions that are often comorbid together into one diagnosis-related group to account for the contribution of each diagnosis to days needed for care. d. DRGs are used by hospitals to provide effective patient care while remaining profitable.

Important interventions may be missed or may be inappropriate.

During shift handoff, the outgoing nurse tells the incoming nurse that the assessments done on patients were a few hours ago due to a late admission. The nurse begins to plan out the day immediately after obtaining reports for the five assigned patients. Which pitfall is most likely to occur in this situation? a. Important interventions may be missed or may be inappropriate. b. Important patient preferences may not be considered by the nurse. c. Tasks may be inappropriately delegated to other healthcare team members. d. Easier tasks may be planned for completion prior to more complicated tasks.

A middle-aged adult complaining of sinus headache and possible sinus infection

The emergency department nurse is triaging patients for the urgent or nonurgent track. Which patient should the nurse triage into the nonurgent track? a. A middle-aged adult complaining of sinus headache and possible sinus infection b. An infant with severe flu symptoms c. An older adult who fell at home and whose family is unsure if the patient experienced a head injury from the fall d. A school-aged child having an allergic response to a bee sting

Having ancillary personnel contact the affiliated hospital or local medical supply store to see if they have the needed dressings

The home care nurse is planning the schedule of patients for the day. The nurse notes that there is a shortage of wound dressings needed for a new patient admitted for wound care post-hospitalization. The new supplies are also not likely to arrive in time for the scheduled visit. Which action should the nurse take to provide the best patient care for all scheduled patients for the day? a. Having ancillary personnel contact the affiliated hospital or local medical supply store to see if they have the needed dressings b. Personally contacting the medical supplier and asking when the dressings can be delivered c. Contacting the patient's family and asking them to contact the provider to see if the dressings are available to complete the dressing change d. Rescheduling the patient's initial appointment for the following day

"The nursing plan of care helps to organize information about the patient's nursing care and ensures appropriate, individualized treatment."

The nurse admitting a patient asks the family if they would be available to help provide information to support the development of the nursing plan of care. The family asks the nurse what a nursing plan of care is. Which response by the nurse answers this question? a. "The nursing plan of care helps to organize information about the patient's nursing care and ensures appropriate, individualized treatment." b. "It will provide daily information about when the patient will be bathed, taken to the dining room for meals, and so forth." c. "A nursing plan of care helps us to organize and coordinate all of the provider's orders in one place for easy reference." d. "A nursing plan of care just refers to the daily medications and labs that the patient will be receiving."

Date the plan was written and initiating nurse's signature

The nurse auditor is reviewing several patient charts to evaluate the effectiveness of the nursing care provided. Which information should the auditor look for that demonstrates nursing accountability and is essential for evaluation? a. Use of standardized nursing diagnoses b. Use of the phases of the nursing process as category headings c. Date the plan was written and initiating nurse's signature d. Customization of the plan to include patient choices and preferences

Noticing

The nurse auscultates a patient's breath sounds after the patient receives an albuterol nebulizer treatment secondary to wheezing. The nurse finds that the patient is still wheezing despite the therapy. Which aspect of Tanner's clinical judgment model is the nurse displaying? a. Interpreting b. Responding c. Noticing d. Reflecting

Clinical decision-making

The nurse decides to suction and perform tracheostomy care on a patient before sending the patient to a scheduled procedure. Which process does the nurse's action define? a. Intuition b. Clinical decision-making c. Trial and error d. Choosing among alternatives

"To learn from actions in order to make adjustments to future practice"

The nurse educator is reviewing Tanner's clinical decision-making model and asks the students about the purpose of reflecting. Which response by a student is correct? a. "To learn from actions in order to make adjustments to future practice" b. "To gain understanding about a situation" c. "To sense what is happening in a situation" d. "To analyze a situation to choose an action"

"Both clinical decision making and critical thinking are important parts of nursing judgment."

The nurse educator is teaching student nurses about nursing judgment. Which statement by a student indicates effective learning? a. "Both clinical decision making and critical thinking are important parts of nursing judgment." b. "Students must be skilled at using clinical judgment while in nursing school." c. "Clinical decision making is scarcely used in nursing judgment." d. "Intuition is an important part of nursing judgment in the new nurse."

Interpreting

The nurse forgets to provide the patient with discharge papers. When speaking with a coworker, the nurse states, "I should have remembered to bring the papers into the patient's room, but I got distracted with another task." Which guided reflection task is the nurse demonstrating? a. Interpreting b. Observing c. Reflecting d. Responding

Caregiver Role Strain, Risk for

The nurse has been using a standardized care plan to guide care for a patient hospitalized following open heart surgery. The patient is not married and lives with his 85-year-old mother who has unstable diabetes and congestive heart failure. Which nursing diagnosis would require the nurse to create an individual plan to supplement the standardized plan? a. Self-care Deficit: Toileting b. Cardiac Output, Decreased, Risk for c. Caregiver Role Strain, Risk for d. Tissue Integrity, Impaired

Allow the patient to wear pajamas from home as per patient request.

The nurse has created a nursing plan of care for a patient with an intellectual disability who is hospitalized for a surgical procedure. Which nursing intervention reinforces the patient's individuality and sense of control? a. Assess the patient's ability to independently complete activities of daily living (ADLs). b. Allow the patient to wear pajamas from home as per patient request. c. Encourage the patient to discuss any fears related to the surgery. d. Teach the patient how to turn and reposition self every 2 hours after surgery.

The healthcare provider will write an order for the appropriate clinical pathway for this patient.

The nurse has just admitted a 72-year-old patient for total hip replacement to a unit that utilizes clinical pathways. The patient is otherwise healthy, and recovery is expected to progress normally. How will the clinical pathway for this patient be initiated? a. The healthcare provider will write an order for the appropriate clinical pathway for this patient. b. The physical therapist will initiate the clinical pathway for this patient if appropriate. c. The nurse will initiate the clinical pathway after verification of appropriateness by the nursing supervisor. d. The nurse will complete a patient assessment to determine if the patient meets the parameters for the clinical pathway, then initiate it.

A 33-year-old patient admitted with a new diagnosis of hepatic cancer who is tearful and very anxious

The nurse is assigned to four patients. In the shift report, the outgoing nurse shares the various upcoming needs and issues that the incoming nurse will need to address. Which patient's needs should the nurse classify as medium priority? a. A 67-year-old patient with deep vein thrombosis who recently started coumadin therapy b. A 52-year-old stroke patient who is dealing with severe dysphagia and impaired ability to clear the airway of mucus c. A 90-year-old patient who is admitted secondary to inability to care for self and awaiting transfer to a long-term care facility d. A 33-year-old patient admitted with a new diagnosis of hepatic cancer who is tearful and very anxious

Deciding to bathe the patient before therapy

The nurse is beginning a new shift and is reviewing the report given by the previous nurse. Which decision by the nurse is an example of a scheduling decision? a. Deciding what information to share with other healthcare providers b. Deciding when to change a dressing c. Deciding to bathe the patient before therapy d. Deciding what can be completed by a nursing assistant

Allowing the child to help the care provider whenever possible

The nurse is caring for a 3-year-old and an 8-year-old patient who are sharing the same room. Which intervention is appropriate for the 8-year-old but not the toddler? a. Allowing the child to help the care provider whenever possible b. Providing age-appropriate explanations c. Giving options when appropriate d. Using play therapy and dolls and toys to explain treatments

Inquiry

The nurse is caring for a neonate who requires nasogastric (NG) tube feedings due to prematurity. The NG tube frequently slips out of position, and the nurse tries different approaches to prevent this from happening. Which critical thinking skill is the nurse demonstrating? a. Intellect b. Reasoning c. Inquiry d. Reflection

Inclusion of medical treatments to be performed by different providers

A facility has decided to use clinical pathways to guide multidisciplinary care for patients on the cardiac unit. This decision was made due to the multidisciplinary nature of clinical pathways. Which information included in the pathway best supports multidisciplinary use? a. Inclusion of clinical interventions and time frames for completion b. Inclusion of projected length of stay and daily sequence of care by providers c. Inclusion of usual expectations of response and expected outcomes d. Inclusion of medical treatments to be performed by different providers

Continuity of care

A healthcare team member accesses a patient's nursing plan of care because the nurse is currently unavailable. Which patient outcome is enhanced by this action? a. Adequate reimbursement for services provided b. Standardization of care c. Continuity of care d. Establishment of a clinical pathway

Clinical pathway

A healthcare team on an orthopedic unit is discussing ways to reduce cost, increase efficiency, and improve patient outcomes while collaboratively providing care. Which approach to care would be most useful in guiding daily, multidisciplinary care for the patient population on this unit? a. Standardized care plan b. Clinical pathway c. Column care plan d. Concept map

Effectiveness and efficiency

A recently hired graduate nurse is having difficulty establishing a workflow, which is affecting the quality of patient care provided. The nurse manager discusses setting priorities, managing time, and delegating to staff as strategies the new graduate can use. Which qualities that affect patient perception of nursing care are supported through use of these strategies? a. Accountability and responsibility b. Adaptability and flexibility c. Effectiveness and efficiency d. Empathy and caring

"Make sure to take short breaks away from the unit during each shift even if it is difficult to do."

A medical-surgical nurse at a busy hospital is mentoring a new graduate nurse. Which advice should the nurse provide to the new graduate to best help relieve stress and break up the intensity of the work environment? a. "Make sure to take short breaks away from the unit during each shift even if it is difficult to do." b. "Spend time each evening when you get home preparing for your shift the next day by looking up those things that are unfamiliar to you." c. "Always remember that we all make mistakes, but work hard to make sure that they are few and not serious." d. "If you are unsure about something, please ask rather than being worried and stressed. We are always willing to answer any questions."

Ensure standardization of care provided across clinical disciplines.

A respiratory therapist is working with pediatric patients with cystic fibrosis. When the therapist asks the nurse about treatment guidelines for the patient, the nurse refers the therapist to a clinical pathway algorithm. Which describes the goal of this algorithm? a. Ensure standardization of care provided across clinical disciplines. b. Provide a visual depiction of the nursing care plan. c. Improve time efficiency when providing care for patients. d. Define interventions for which each discipline will be held accountable.

Obtaining an order for intravenous fluids at 100 mL/hr

A 64-year-old patient is receiving chemotherapy for breast cancer. After the morning report, the nurse finds the patient nauseated, vomiting light green emesis, and crying because her hair is falling out in clumps. The pulse is 110 beats/min and thready, and the blood pressure is 96/50 mmHg. Which intervention should the nurse make priority for this patient? a. Obtaining an order for intravenous fluids at 100 mL/hr b. Cleansing the skin and applying a clean hospital gown c. Premedication for nausea before the next chemotherapy dose d. Teaching the patient some deep-breathing exercises to help her calm down

Reflecting

A new nurse is speaking with a mentor about a mistake made the day before. The mentor encourages the nurse to review the situation and make a mental note to respond differently the next time the situation occurs. Which process is the mentor encouraging? a. Responding b. Reflecting c. Interpreting d. Noticing

Subjective data

A patient presents to the emergency department with high fever and coughing. Which information should the nurse collect for analysis? a. Judgments b. Inferences c. Opinions d. Subjective data

"A standardized plan is a set of common interventions that can be individualized for patients with the same diagnosis, which is different from standards of care."

A peer tells a new nurse that there is a standardized plan that can be used for a patient diagnosed with diabetes. The nurse asks the peer how standards of care can be helpful in developing a plan of care for this patient. Which response by the peer best answers this question? a. "The standards of care can be very helpful in these situations because they set benchmarks for nursing performance expectations." b. "A standardized plan is a set of common interventions that can be individualized for patients with the same diagnosis, which is different from standards of care." c. "Standards of care and standardized care plans refer to the same thing; they are very helpful in supporting the provision of evidence-based care." d. "Standards of care underlie the development of standardized plans; they are used to determine which nursing interventions should be included in the standardized plan."

Paternalism

A pregnant patient presents with rising blood pressure and protein in her urine. After testing, the provider diagnoses the patient with preeclampsia and informs her that they are taking her to the operating room to deliver the baby through cesarean delivery immediately. Which decision-making model is displayed? a. Consumerism b. Mutualism c. Paternalism d. Maternalism

Nursing process

A recently graduated nurse asks a mentor for guidance concerning how to determine priorities when working with patients. Which process codified by the American Nurses Association (ANA) should the mentor refer to as a useful framework? a. Clinical decision-making process b. Evidence-based process c. Quality-improvement process d. Nursing process

A 36-year-old who is 32 weeks pregnant with her first child and is experiencing difficulty breathing

An emergency department nurse is organizing care for several patients admitted following a multiple-vehicle crash. Which patient should the nurse classify as having critically urgent needs? a. A 72-year-old with a small gash above the right eye that has currently stopped bleeding b. A 36-year-old who is 32 weeks pregnant with her first child and is experiencing difficulty breathing c. A 5-year-old with multiple bumps and bruises who is frightened and anxious d. A 16-year-old patient who is complaining of pain in the right wrist and has an immobilizer in place

Priority 2: Should do

An unlicensed assistive personnel (UAP) has asked the nurse for assistance ambulating an 87-year-old patient who is on postoperative day 3 following a knee replacement. As which level of priority should the nurse classify this request when organizing the activities of the day? a. Priority 2: Should do b. Priority 1: Must do c. Priority 1: Vital to do d. Priority 3: Nice to do

Goals/desired outcomes

In which column in a plan of care should the nurse place this information: "Patient will walk 100 feet two times each shift"? a. Nursing interventions b. Evaluation c. Assessment d. Goals/desired outcomes

Infusing intravenous fluids

The nurse is caring for a patient who is admitted with erosive gastritis. Blood pressure on admission was 136/68 mmHg with a heart rate of 94 beats/min. Currently, the patient's blood pressure is 74/52 mmHg with a heart rate of 138 beats/min. Which healthcare provider prescription should the nurse initiate first? a. Infusing intravenous fluids b. Initiating gastric lavage c. Testing stool for occult blood d. Infusing drugs to reduce gastric acidity

Place cots for parents to stay over in all patient rooms.

The nurse is looking at ways to help infants in the healthcare process. Which intervention is appropriate for this age group? a. Encourage the use of play therapy and toys in the treatment rooms. b. Provide simple options when appropriate. c. Allow for hands-on exploration of all equipment. d. Place cots for parents to stay over in all patient rooms.

Patient cognitive status and presence of several family members

The nurse is performing an admission assessment for hospice for a patient who has significant declines in health and cognitive capabilities. The patient's spouse and three children are present. Which factor will most likely impact the amount of time needed to complete this admission? a. Inability to ask the patient directly about preferences related to care b. Inability to complete certain patient-specific aspects of the assessment process c. Patient cognitive status and presence of several family members d. Regulations of insurance providers and home care agency concerning amount of assessment information required

Discuss the advantages of the facility that is a bit farther away.

The nurse is planning to transfer a 76-year-old patient to a long-term care facility. The patient wants to live close to family; however, the facility that would best meet the patient's needs is a few miles farther away. Which action should the nurse implement? a. Discuss the advantages of the facility that is a bit farther away. b. Tell the patient that being near family is not always a good idea. c. List other facilities so that the patient can make a better decision. d. Tell the patient that the facility that is closer to family is not accepting admissions.

Failure to do periodic reassessment

The nurse is preparing to administer insulin coverage to an assigned patient who has just finished breakfast. It is now 0830, and the nurse is basing coverage on the blood sugar result provided in the report at 0600 during the change of shift. Which common pitfall is occurring in this situation that may result in a negative patient outcome? a. Poor time management b. Failure to do periodic reassessment c. Doing the easiest task first d. Incomplete assessment

Allow the family to provide a warm bath in the evening as allowed by the provider.

The nurse is providing care for a 3-year-old hospitalized child. As the nurse creates the nursing plan of care, the family informs the nurse that they usually give the toddler a warm bath every night before bed. How should the nurse best address this in the nursing plan of care? a. Allow the family to provide a warm bath in the evening as allowed by the provider. b. Teach the family the importance of helping the toddler adjust to hospital routines, including a morning bath. c. Instruct nursing assistive personnel to provide bath per unit guidelines every other day in the evening. d. Discuss current plan of care with the family and include the family in planning care as is feasible.

A standardized plan is more time efficient and includes a common set of interventions for a patient with HF.

The nurse is providing care for a new patient admitted with heart failure (HF). The facility in which the nurse works has purchased a set of standardized plans for use. Which is a benefit of using a standardized plan for this patient versus generating an individual plan? a. A standardized plan is more time efficient and includes a common set of interventions for a patient with HF. b. A standardized plan uses evidence to account for all possibilities related to the diagnosis, eliminating the need for individualization. c. A standardized plan can be used to address both predictable and unpredictable problems that occur with HF, thus ensuring flexibility for many patient variations. d. A standardized plan is a multidisciplinary plan that becomes a part of the permanent patient record, thus making documentation easier.

Report of difficulty breathing

The nurse is reviewing assessment data collected from a patient with pneumonia. Which data should the nurse identify as subjective? a. Report of difficulty breathing b. Presence of cough c. Observation of yellow sputum d. Rapid breathing

Mutualism

The nurse is sitting with a laboring patient who is requesting intermittent fetal monitoring. The nurse is explaining the risks, benefits, and evidence to support the different types of monitoring. Which type of decision making is the nurse demonstrating? a. Consumerism b. Mutualism c. Paternalism d. Maternalism

Consumerism

The nurse is sitting with the healthcare provider and a pregnant patient. The provider is explaining to the pregnant woman the various options for genetic testing that are currently available. The provider asks the patient which testing she would like to have done. The nurse understands that the provider is displaying which decision-making model? a. Mutualism b. Maternalism c. Paternalism d. Consumerism

Concept map

The nurse is struggling to see the "whole picture" when caring for a patient with very complex needs. Which method for developing the plan of care should the nurse consider? a. Column plan b. Standardized plan c. Clinical pathway d. Concept map

Preset diagnosis-related groups (DRGs) determine the number of days allowed for this diagnosis and thus the number of columns.

The nursing team is reviewing the possible use of clinical pathways to guide care for patients on the pulmonary care unit. One of the team members asks how the number of columns is determined for the clinical pathway. Which response by the team facilitator provides the best explanation? a. Preset diagnosis-related groups (DRGs) determine the number of days allowed for this diagnosis and thus the number of columns. b. Each insurer determines the number of days it will cover for a patient related to the specific diagnosis, which determines the number of columns. c. The number of columns is preset regardless of diagnosis and includes assessment, pretreatment, and treatment of the specified diagnosis. d. Column numbers vary by each patient's diagnosis, patient age, and existence of comorbidities; thus, the number of columns can vary widely between patients.

More time may be needed to establish IV access.

The pediatric nurse is preparing to establish intravenous (IV) access for a toddler who is admitted with high fever and inconsolable crying. The toddler has been very uncooperative with admission procedures because the child's mother is not with the child. Which factor should the nurse take into consideration when planning the time needed for this procedure? a. More time may be needed to establish IV access. b. Toddlers can be difficult, but the time required to establish IV access is generally the same across this age group. c. A sedative may be needed, so the nurse should allow time for the sedative to take effect. d. Less time will be needed to obtain IV access because the toddler can easily be restrained by staff if needed.

The scientific method

The school nurse is looking at the effects that increasing recess and recreation time has in the classroom. The nurse plans to assign some classes within the school an additional hour of recess each day, and the remaining classes will stay on the current schedule. Which concept of problem solving and critical thinking should be most useful in this situation? a. Intuition b. The nursing process c. Trial and error d. The scientific method

Determining which tasks could be appropriately delegated to other personnel, allowing more flexibility for the nurse to adapt to any changes

The trauma unit nurse is planning out the day before a holiday weekend based on the current patient assignments. Which action should the nurse perform to best support effective time management and address unexpected occurrences and changes in the condition of patients? a. Determining which tasks could be appropriately delegated to other personnel, allowing more flexibility for the nurse to adapt to any changes b. Building several open time frames into the day to allow for activities that may take more time than anticipated c. Sharing the day's plan with the rest of the healthcare team so that they can easily provide assistance if something unanticipated occurs d. Prioritizing necessary activities so that unnecessary activities can be left for the next shift for follow-up if time becomes an issue