Foundations of Nursing - Adaptive Quizzing Chapter 5

The nurse is attending to a patient in a coronary care unit. She is revising the care plan after evaluating the patient outcomes. Which steps of the nursing processes is the nurse performing? Planning Diagnosis Evaluation Assessment Implementation

c, d ) Assessment is the process by which the nurse collects all the data, and revises the care plan after evaluation. Diagnosis, planning, and implementation come later in the process. pp. 73-79

The nurse finds new assessment data in a patient with fever and vomiting. Which step of the nursing process would involve revision of the nursing care plan? Planning Evaluation Assessment Implementation

During the evaluation phase, the nurse assesses the patient's response to the nursing interventions. The nurse will revise the nursing care plan accordingly. If there are any new findings, the nurse revises and modifies the nursing care plan. The nurse prioritizes nursing diagnoses, establishes goals, identifies outcomes, and identifies the specific nursing interventions during the planning phase. Assessment is the first step of the nursing process, which includes the gathering of patient data, including primary or secondary and subjective or objective data. Implementation is the fourth step of the nursing process and involves carrying out the nursing interventions to achieve goals. Test-Taking Tip: To help you recall that revision of the nursing care plan occurs during evaluation, consider that until you have evaluated the patient, there is no need to revise the care plan. You don't know whether the plan is or is not working until evaluation. p. 71

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which of the following describe the nurse's actions? The cleansing of the skin is a direct care measure. The cleansing of the skin is a dependent care measure. The application of the skin barrier is a dependent care measure. The application of the skin barrier is a direct care measure. The call to the ostomy and wound care specialist is an indirect care measure.

a, d, e) The call to the ostomy and wound care specialist is an indirect care measure involving collaborative care. Cleansing the skin is an independent direct care measure. Applying the skin barrier is an independent nursing measure involving direct care. pp. 73-79

The nurse receives a patient in an observation room following a colonoscopy. No written medical prescription is present on the chart. Which patient care measure will the nurse follow to provide care? Protocols Standing orders Protocols and care pathways Care pathways and standing orders

b) In a hospital or health care facility, standing orders are written policies, rules, procedures, and orders for the conduct of patient care in some instances when the primary health care provider is unavailable. Highly skilled members of the healthcare facility prepare these orders. Most commonly used orders are standing orders. A nursing protocol or practice manual is a written document generalized to provide care for a similar group of patients. Every hospital has established protocols within the scope of the healthcare member practice. Clinical pathways are care pathways, critical pathways, and care maps. Evidence-based practice helps the development of care pathways to provide better-quality, standardized care for patients. p. 77

The nurse finds that the patient outcomes have not been achieved after the implementation of interventions. The nurse also identifies aspects of the nursing care plan that need to be modified. Which step of the nursing process do these actions address? Planning Diagnosis Evaluation Assessment

c) The nursing process consists of assessment, diagnosis, planning, implementation, and evaluation. During the evaluation stage, the nurse analyzes the findings for any new data or problems in the patient. Based on these findings, the nurse may modify the nursing care plan. After a thorough and accurate assessment, the nurse prioritizes the needs of the patient and prepares a nursing care plan. The nurse makes a clinical judgment based on the data gathered from the patient during the diagnosis phase. Assessment is the initial step of the nursing process which helps to identify the patient's needs. Test-Taking Tip: Read the question carefully. One way to do this is to imagine hearing the question in your mind as if you are reading it aloud while speaking the words deliberately. In this case, the question explains that the nurse is working AFTER the implementation. (Did you hear the emphasis on AFTER in your imagination?) Knowing the steps in the nursing process, you know that the only step after implementation is evaluation. p. 70