FUND of NURS Ch 18

Setting priorities for a patient's nursing diagnoses or health problems is an important step in planning patient care. Which of the following statements describe elements to consider in planning care? (Select all that apply) 1. Priority setting establishes a preferential order for nursing interventions 2. In most cases wellness problems take priority over problem-focused problems 3. Recognition of symptom patterns helps in understanding when to plan interventions 4. Longer-term chronic needs require priority over short-term problems 5. Priority setting involves creating a list of care needs

1, 3

Which of the following factors should be considered when choosing an intervention for a patient's plan of care? (Select all that apply) 1. the specific patient outcome against which to judge effectiveness of interventions 2. the timing of care activities routinely conducted on the care unit 3. the scientific evidence available in support of an intervention 4. the amount of time for implementation of patient's condition 5. the patient's values and beliefs regarding the intervention

1, 3, 4, 5

A nurse on a hospital unit s preparing to hand off care of a patient being discharged to a home health nurse. Match the activities with the hand off report categories. 1. use a standard checklist for the report 2. encourage questions and clarification 3. offer specific information on how to reduce patient's risks 4. give report at time when shift has ended and other nurses are reporting information 5. explain how patient's discharge was delayed by insufficient members of staff 6. organize time by preparing in advance what to report A. strategy for effective hand-off B. strategy for ineffective hand-off

1. A 2. A 3. A 4. B 5. B 6. A

What are the 6 steps of the nurse's role when seeking consultation?

1. Identify the general problem area 2. direct the consultation to the right professional 3. Provide the consultant with relevant information about the problem area 4. So no prejudice against or influence the consultants . Br available to discuss the findings and recommendations 6. Incorporate the recommendations into the plan of care

An 82-year-old-patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less than Body Requirements related to reduced Ability to Feed self. The nursing staff identified several goals of care. Match the goals with the outcome statements. 1. patient will ambulate independently in 3 days 2. patient will be injury-free for 1 month 3. patient will achieve 5-pound weight gain in one month 4. patient will achieve pain relief by discharge a. patient expresses fewer nonverbal signs if discomfort within 24 hours b. patient increases caloric intake to 2500 calories daily c. patient walks 20 feet using a walker in 24 hours d. patient identifies barriers to remove in the home within 1 week

1. c 2. d 3. b 4. a

Match the elements for correct identification of outcome statements with the SMART acronym terms below: 1. Specific 2. Measurable 3. Attainable 4. Reliable 5. Timed a. Mutually set an outcome that the patient agrees to meet b. set an outcome that the patient can meet based upon his or her physiological, emotional, economic, and sociocultural norms c. be sure an outcome addresses only one patient behavior or response d. include when an outome is to be met e. use a term in an outcome statement that allows for observation as to whether a change takes place in a patient's status

1. c 2. e 3. a 4. b 5. d

Identify the six factors the nurse uses to select nursing interventions for a specific patient.

1. desired patient outcomes 2. characteristics of the nursing diagnosis 3. research base knowledge for the intervention 4. feasibility for doing the intervention 5. acceptability to the patient 6. your own competency

Talk about th e3 components of delegation:

1. responsibility- RN's have a professional duty to perform patient care tasks dependably and reliably 2. authority- refers to an individual's ability to complete duties within a specific role 3. accountability-legal liability for actions related to patient care. Even though something has been delegated, the RN is still accountable

Name the 5 rights of delegation

1. right task 2. right circumstance 3. right person 4. right supervision 5. right direction and communication

Identify some factors within a hospital that affect ability to set priorities.

1. the model for delivering care 2. the workflow routine of a nursing unit 3. staffing levels 4. availability of material resources 5. interruptions from other care providers

Identify some factors within a home health setting that affect your ability to set priorities

1. the number of visits scheduled for a day 2. availability of family caregivers 3. resources within a patient's home

A nurse is assigned to care for six patients at the beginning of the night shift. The nurse learns that the floor will be short by one RN as a result of a call-in. A patient care technician from another area is coming to the nursing unit to assist. Because the unit requires hourly rounds on all patients, the nurse begins to mae rounds in a patient who recently asked for a pain medication, The nurse is interrupted by another RN who asks about another patient. Which factors in this nurse's unit environment will affect the ability to set priorities? (Select all that apply) 1. policy for conducting hourly rounds 2. staffing level 3. interruption by staff nurse colleague 4. type of hospital unit 5. competency of patient care technician

2, 3, 5

A patient diagnosed with colon cancer has been receiving chemotherapy for 6 weeks. the patient visits the center twice a week for infusions., The nurse assigned to the patient is having difficulty accessing the patient's IV port used to administer the chemo. Despite attempts to flush the port, it is obstructed. This also occurred 2 weeks earlier. What steps should the nurse follow to make a consultation with a member of the IV team? (select all that apply) 1. ask the IV nurse to come to the infusion center at a time when the nurse starts care for a second patient 2. specifically identify the problem of port obstruction and attempt to flush the port to solve the problem 3. explain to the IV nurse the frequency in which the port has obstructed in the past 4. tell the IV nurse the problem is probably related to the physician who inserted the port 5. describe to the IV nurse the type and condition of the port currently in use

2, 3, 5

The following statement appears on the nursing care plan for an immunosuppressed patient: "The patient will remain free from infection throughout hospitalization." This statement is an example of a (an): 1. Long-term goal 2. Short-term goal 3. Nursing diagnosis 4. Expected outcome

2. An objective behavior or response that you expect a patient to achieve in a short time, usually less than 1 week

A nursing student is providing a handoff report to an RN who is assuming her patient's care at the end of the clinical day. The student states," The patient had a good ay, His IV fluid is infusing at 124 mL/hr with D51/2NS infusing in left forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated walking to the visitor's lounge and back with no SOB, respirations 14, and heart rate 88 after exercise, He uses his walker without difficulty, gait normal. The patient ate 3/4 of his dinner with no gastro complaints. For the goal of improving the patient's activity tolerance, which expected outcomes were shared in the hand-off? (select all that apply) 1. IV site not tender 2. uses a walker to walk 3. walked to the visitor's lounge 4. no shortness of breath 5. tolerated dinner meal

3, 4

A nursing student is providing a hand-off report to the RN assuming her patient's care. She explains, "I ambulate him twice during a shift; he tolerated walking to end of hall each time and back with no shortness of breath, Heart rate was 88 and regular after exercise. The patient said he slept better last night after I closed his door and gave him a chance to have some uninterrupted sleep. I changes the dressing over his IV site and started a new bag of D51/2 NS. Which intervention is a dependent intervention?

3. Administering IV fluids

The planning step of the nursing process includes which of the following activities? 1. Assessing and diagnosing 2. Evaluating goal achievement 3. Setting goals and selecting interventions 4. Performing nursing actions and documenting them

3. The nurse sets patient-centered goals and expected outcomes and plans nursing interventions.

The following statements appear on a nursing care plan for a patient after a mastectomy: "Incision site approximated; absence of drainage or prolonged erythema at incision site; and patient remains afebrile." These statements are examples of: 1. Long-term goals 2. Short-term goals 3. Nursing diagnosis 4. Expected outcomes

4. The measurable change in a patient's condition that you expect to occur in response to the nursing care

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240lbs) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the past 2 days, The nurse identifies the nursing diagnosis if Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? 1. patient will be turned every 2 hours within 24 hours 2. patient will have normal formed stool within 48 hours patient's ability to turn self in bed improves 4. erythema of skin will be mild within 48 hours

4. erythema of skin will be mild within 48 hours

Describe Realistic in the SMART model

A realistic goal or outcome is one that a patient is able to achieve.

Describe Timed in the SMART model

A time-limited outcome is written so that it indicates when the nurse expects the response to occur.

The nursing care plan is: A. A written guideline for implementation and evaluation. B. A documentation of client care. C. A projection of potential alterations in client behaviors D. A tool to set goals and project outcomes.

A. A written guideline for implementation and evaluation.

For clients to participate in goal setting, they should be: A. Alert and have some degree of independence. B. Ambulatory and mobile. C. Able to speak and write. D. Able to read and write.

A. Alert and have some degree of independence.

To initiate an intervention the nurse must be competent in three areas, which include: A. Knowledge, function, and specific skills B. Experience, advanced education, and skills. C. Skills, finances, and leadership. D. Leadership, autonomy, and skills.

A. Knowledge, function, and specific skills

When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: A. Length of time the current treatment has been in place B. The spouse's reaction to the client's dressing change C. Client's concern about the current treatment D. Physician's reluctance to change the current treatment plan

A. Length of time the current treatment has been in place This gives the consulting nurse facts that will influence a new plan. Other choices are all subjective and emotional issues about the current treatment plant and may cause bias in the decision of a new treatment plan by the nurse consultant.

Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses: A. Plan is developed for nursing care. B. Physical assessment begins. C. List of priorities is determined. D. Review of the assessment is conducted with other team members.

A. plan is developed for nursing care

The RN has received her client assignment for the day-shift. After making the initial rounds and assessing the clients, which client would the RN need to develop a care plan first? A. A client who is ambulatory. B. A client, who has a fever, is diaphoretic and restless. C. A client scheduled for OT at 1300. D. A client who just had an appendectomy and has just received pain medication.

B. A client, who has a fever, is diaphoretic and restless.

As goals, outcomes, and interventions are developed, the nurse must: A. Be in charge of all care and planning for the client. B. Be aware of and committed to accepted standards of practice from nursing and other disciples. C. Not change the plan of care for the client. D. Be in control of all interventions for the client.

B. Be aware of and committed to accepted standards of practice from nursing and other disciples.

A client's wound is not healing and appears to be worsening with the current treatment. The nurse first considers: A. Notifying the physician B. Calling the wound care nurse C. Changing the wound care treatment D. Consulting with another nurse

B. Calling the wound care nurse Calling in the wound care nurse as a consultant is appropriate because he or she is a specialist in the area of wound management. Professional and competent nurses recognize limitations and seek appropriate consultation. (a. This might be appropriate after deciding on a plan of action with the wound care nurse specialist. The nurse may need to obtain orders for special wound care products. c. Unless the nurse is knowledgeable in wound management, this could delay wound healing. Also, the current wound management plan could have been ordered by the physician. d. Another nurse most likely will not be knowledgeable about wounds, and the primary nurse would know the history of the wound management plan.)

The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis? A. A client's family attending a diabetic teaching session. B. Canceling physical therapy sessions on the weekend. C. Normal VS and absence of wound infection in a post-op client. D. A client demonstrating accurate medication administration following teaching.

B. Canceling physical therapy sessions on the weekend.

When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: A. Apply a cold pack to the tibia. B. Elevate the leg 5 inches above the heart. C. Perform range of motion to right leg every 4 hours. D. Administer aspirin 325 mg every 4 hours as needed

B. Elevate the leg 5 inches above the heart. This does not require a physician's order. (A & D require an order; C is not appropriate for a fractured tibia)

A client-centered goal is a specific and measurable behavior or response that reflects a client's: A. Desire for specific health care interventions B. Highest possible level of wellness and independence in function. C. Physician's goal for the specific client. D. Response when compared to another client with a like problem.

B. Highest possible level of wellness and independence in function.

When establishing realistic goals, the nurse: A. Bases the goals on the nurse's personal knowledge. B. Knows the resources of the health care facility, family, and the client. C. Must have a client who is physically and emotionally stable. D. Must have the client's cooperation.

B. Knows the resources of the health care facility, family, and the client.

The following statement appears on the nursing care plan for an immunosuppressed client: The client will remain free from infection throughout hospitalization. This statement is an example of a (an): A. Nursing diagnosis B. Short-term goal C. Long-term goal D. Expected outcome

B. Short-term goal

The nurse writes an expected outcome statement in measurable terms. An example is: A. Client will have less pain B. Client will be pain free. C. Client will report pain acuity less than 4 on a scale of 0-10 D. Client will take pain medication every 4 hours around the clock

C. Client will report pain acuity less than 4 on a scale of 0-10

Planning is a category of nursing behaviors in which: A. The nurse determines the health care needed for the client. B. The Physician determines the plan of care for the client. C. Client-centered goals and expected outcomes are established. D. The client determines the care needed.

C. Client-centered goals and expected outcomes are established.

Which of the following nursing interventions are written correctly? (Select all that apply.) A. Apply continuous passive motion machine during day B. Perform neurovascular checks C. Elevate head of bed 30 degrees before meals D. Change dressing once a shift

C. Elevate head of bed 30 degrees before meals It is specific in what to do and when.

Define collaborative interventions

Collaborative interventions are interdependent nursing interventions that require the combined knowledge, skill, and expertise of multiple care professionals.

After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. 1. Constipation 2. Anticipated grieving 3. Ineffective airway clearance 4. Ineffective tissue perfusion. A. 3, 4, 2, 1 B. 4, 3, 2, 1 C. 1, 3, 2, 4 D. 3, 4, 1, 2

D. 3, 4, 1, 2

Well formulated, client-centered goals should: A. Meet immediate client needs. B. Include preventative health care. C. Include rehabilitation needs. D. All of the above.

D. All of the above.

The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to: A. Implement the specialist's recommendations B. Report the recommendations to the primary physician C. Clarify the suggestions with the client and family members D. Discuss and review advised strategies with CNS

D. Discuss and review advised strategies with CNS Because the primary nurse requested the consultation, it is important that they communicate and discuss recommendations. The primary nurse can then accept or reject the CNS recommendations. (a. Some of the recommendations may not be appropriate for this client. The primary nurse would know this information. A consultation requires review of the recommendations, but not immediate implementation. b. This would be appropriate after first talking with the CNS about recommended changes in the plan of care and the rationale. Then the primary nurse should call the physician. c. The client and family do not have the knowledge to determine whether new strategies are appropriate or not. Better to wait until the new plan of care is agreed upon by the primary nurse and physician before talking with the client and/or family.)

The most important nursing intervention to correct skin dryness is: A. Avoid bathing the patient until the condition is remedied, and notify the physician B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear C. Consult the dietitian about increasing the patient's fat intake, and take necessary measures to prevent infection D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas

D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas Question 1 Explanation: Dry skin will eventually crack, ranking the patient more prone to infection. To prevent this, the nurse should provide adequate hydration through fluid intake, use nonirritating soaps or no soap when bathing the patient, and lubricate the patient's skin with lotion. Bathing may be limited but need not be avoided entirely. The attending physician and dietitian may be consulted for treatment, but home-laundered items usually are not necessary.

The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at incision site; and client remains afebrile. These statements are examples of: A. Nursing interventions B. Short-term goals C. Long-term goals D. Expected outcomes

D. Expected outcomes

Collaborative interventions are therapies that require: A. Physician and nurse interventions. B. Nurse and client interventions. C. Client and Physician intervention. D. Multiple health care professionals.

D. Multiple health care professionals.

After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: A. Encourage client to implement guided imagery when pain begins. B. Determine effect of pain intensity on client function. C. Administer analgesic 30 minutes before physical therapy treatment. D. Pain intensity reported as a 3 or less during hospital stay.

D. Pain intensity reported as a 3 or less during hospital stay. This is measurable and objective.

The planning step of the nursing process includes which of the following activities? A. Assessing and diagnosing B. Evaluating goal achievement C. Performing nursing actions and documenting them D. Setting goals and selecting interventions

D. Setting goals and selecting interventions

Which of the following statements about the nursing process is most accurate? A. The nursing process is a four-step procedure for identifying and resolving patient problems. B. Beginning in Florence Nightingale's days, nursing students learned and practiced the nursing process. C. Use of the nursing process is optional for nurses, since there are many ways to accomplish the work of nursing. D. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept.

D. The state board examinations for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept. Option A: The nursing process is a five-step process. Option B: The term nursing process was first used by Hall in 1955. Option C: Nursing process is not optional since standards demand the use of it.

Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client's: A. Physician B. Non Emergent, non-life-threatening needs C. Future well-being D. Urgency of problems

D. Urgency of problems

Ordering a prescription for a patient is what type of nursing intervention?

Dependent intervention

Define dependent nursing interventions

Dependent nursing interventions are physician-initiated interventions that require an order from a physician or other health care professional. ex: administering medication, implementing an invasive procedure, inserting a foley cath, starting an IV, preparing a patient for diagnostic tests

Describe Attainable in the SMART model

For a patient's health to improve, he or she must be able to attain the outcomes of care that are set; mutually set attainable goals and outcomes.

Explain a high priority

If untreated, result in harm to the patient or others ex: airway status, circulation, safety, and pain (ABC)

Educating a patient on the importance of their medication so they can administer it as prescribed is an example of which type of nursing intervention?

Independent intervention

What category of intervention is the following scenario? A patient recovering from knee surgery who is prescribed pain medication by a physician, administered medication by a nurse, and given physical therapy exercises by a specialist?

Interdependent nursing intervention

What is the difference between interdependent and dependent nursing interventions?

Interdependent nursing interventions are actions that are implemented in a collaboration or consultation with other health care professionals. Dependent nursing interventions require an order from other health care professionals.

What does planning involve?

Planning involves setting priorities based on patient diagnoses and collaborative problems, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions appropriate for each diagnosis.

Explain the SMART approach to writing goal and outcome statements.

Specific Measurable Attainable Realistic Timed

Define the purposes of a nursing care plan

The nursing care plan should direct clinical nursing care and decrease the risk of incomplete, incorrect, or inaccurate care. It identifies and coordinates resources for delivering care. It lists the interventions needed to achieve the goals of care.

Explain what an interprofessional care plan is

a plan that includes contributions from all disciplines involved in patient care. It focuses on patient priorities and improves the coordination of patient therapies and communication among all disciplines.

What is consultation?

a process in which the nurse seeks the expertise of a specialist to identify ways to handle problems in patient management or the planning and implementation of therapies.

A nurse completes a respiratory assessment on a patient who had abdominal surgery 1 day ago. During the assessment, the nurse auscultates crackles in both lower lobes, and the patient coughs, producing light yellow sputum. The patient's temperature is 37° C, pulse is 110 beats/min, respiratory rate is 28 breaths/min, and blood pressure is 118/82 mm Hg. Pulse oximetry was 99% and is now 93%. The nurse identifies a nursing diagnosis of Impaired gas exchange. a. What type of priority is this? b. b. What is a goal for this patient?

a. High priority b. patient's lungs will be clear to auscultation

Describe Specific in the SMART model

addresses only one behavior or response

What is a short-term goal?

an objective behavior or response that you expect the patient to achieve in a short time, usually less than a week. In acute care, it can be just a few hours

What is a long-term goal?

an objective behavior or response that you expect the patient to achieve, usually over several days, weeks, or months

Explain low priority

are not always related to a specific illness or prognosis, but affect a patient's well being

Define independent nursing interventions

interventions that a nurse initiates in response to a nursing diagnosis without supervision, direction, or orders from others ex: positioning patients to prevent pressure injury formation, initiating early mobility protocols, offering counseling for coping, instructing patients in side effects of medications

Explain intermediate priority

involve non-emergent, non-life-threatening needs of the patient ex: risk of infection

Explain the concept of nursing hand offs as a practice of communication information at the end of a shift

nurses collaborate and share information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions

What does a nursing care plan include?

nursing diagnoses, goals and/or expected outcomes, individualized nursing interventions, and a section for evaluation findings. It promotes continuity of care and better communication.

Describe Measurable in the SMART model

terms that describe quality, quantity, frequency, length, or weight allow a nurse to evaluate outcomes precisely