NSG 1130 Evening EAQ #2
Which benefit would the nurse associate with using standard, formal,nursing diagnostic statements. (SATA)
-Foster development of nursing knowledge -provides precise definition of the clients problem -distinguishes the nurses role from that of other care providers The use of standard formal nursing diagnostic statements foster the development of nursing knowledge, which is important to be able to assess a clients specific risk for problems, identify them early, and take preventive action.
Which information would the nurse provide to clients regarding benefits of electronic health records(EHR)(SATA)
-Obtains Medicare and Medicaid payments - shares personal health information with selected family members. - provide more accurate diagnoses and treatment in emergency situation
Utilizing the nursing process, in which order would the nurse provide care for a client who reports experiencing chest pain?
-Perform a focused assessment of the client -Determine the most appropriate NANDA-I diagnosis for the client. -create care plan to minimize the clients symptoms -Administer 2 L of oxygen via nasal cannula. Rationale: the nurse would first perform an assessment to look for subjective and objective data, next she/he would formulate a nursing diagnoses that best represent ps what is happening with the client. Creation of a care plan based on the diagnosis is next step, followed by implementation of the identified intervention, such as administration of oxygen
Which action would the nurse take to obtain subjective data about a client's respiratory status?(SATA)
-Question the client about shortness of breath -ask the client about color of quantity Rationale: subjective data is collected directly from the client. During respiratory assessment, the nurse would ask the client about any SOB and about the color and quantity of any sputum produced. The nurse would palpate the chest and masses while collecting objective data during physical examination. The nurse checks hematocrit and hemoglobin values while collect objective diagnostic data. The nurse inspects client skin for integrity and color to determine oxygenation of tissues.
Which information would the registered nurse provide to the nursing student regarding identifying and eliminating potential hazards(SATA)
-ensure that the three principles of the joint commissions universal protocol are adhered to before starting a surgery on a client. -refrain from depending on the use of electronic monitoring devices completely because they are not always reliable -file an occurrence report in case of an error technique when administering medication intravenously
Which feature distinguishes nursing diagnosis from medical diagnosis
-nursing diagnoses involve the client when possible -nursing diagnoses involve the sorting of health problems within the nursing domain -nursing diagnoses involve clinical judgment about clients response to health problems Rationale: establishing a nursing diagnosis is the second step in the nursing process. Nursing diagnoses classify health problems to be treated by the nurse
Place the steps of the nursing process in order.
1. Identify the clients health care need by collecting subjective and objective data 2. Define the nursing diagnoses or collaborative problems clearly 3. Plan the care by determine priorities,goals,and expected outcomes of care 4. Perform nursing interventions completely 5. Evaluate the effects of the nursing interventions performed Rationale:assessment,diagnosis,plan,implementation,evaluation
Arrange the events of communication throughout the nursing process in chronological order
1.assessing the medics, record and diagnostic tests 2 .intrapersonal analysis of the assessment findings 3. Documenting expected outcomes 4.performing verbal, visible, auditory, and tactile health teaching activities 5. Identifying factors affecting the outcomes
The nurse is preparing an intraoperative care plan for a client. Which intervention would the excluded from the care plan?
Administering a general anesthetic to the client Rationale: on anesthesiologists who are specially trained can administer anesthesia.
Which organization provides scope and practice guidelines on the roles and responsibilities for nursing and nursing specialties
American Nurses Association
In which order would the nurse apply the nursing process while providing care for clients ?
Assessment,diagnosis,planning,implementation,evaluation
Which client would need a correction in nursing intervention
Client 2: administration of Analgesics only when pain intensifies Rationale: When a child has acute pain, oral dosage forms of analgesics should be given. These medications must be given before the pain intensifies, so the nursing intervention for client 2 needs correction. In pediatrics, distraction and creative imagery during the medication administration can help distract the child from any pain or fear, so the nursing intervention for client 1 is appropriate. In pediatrics, opioids can cause certain changes such as nausea and vomiting. Administering the medications with meals can help reduce the gastrointestinal (GI) upset, so the nursing intervention for client 3 is appropriate. While administering suppositories to pediatric clients, care should be taken that an adult dose is halved, split, or divided to reduce the risk of overdose, so the nursing intervention for client 4 is appropriate.
Which type of interview would the nurse utilize when admitting a client to a clinic
Directive Rationale: the first step in the problem solving process is data collection so that the client needs can be identified. During the initial interview a direct approach obtains specific information such as allergies, current medications,and health history. The exploratory approach is too broad because in a nondirective interview the controls the subject matter.
Which activity would the nurse perform under the practice of implementation after learning about the standards of nursing process
Educating patients for health awareness. Using therapeutic procedures for patient care Providing consultation to enhance patient care
Which strategy would improve safety when the nurse manager institutes strategies to decrease the omission of important information during communication between staff nurses and health care providers?
Employ SBAR
Which standard of practice would the nurse perform when evaluating a clients pain after performing s back massage
Evaluation
Which phase of the nursing process is being applied when the nurse revises the care plan because the goals have not been meet?
Evaluation Rationale: evaluation includes the assessing the clients response to care, judging the effectiveness of the plan of care, and changing the plan as necessary. Planning includes the development of a plan focused on specific goals and actions unique to the clients need. Assessment entails collecting and reviewing objective and subjective data about clients health status. Implementation includes performing specific actions designed to achieve the stated goal
Which statement distinguishes evidence based practice from quality improvement?
Evidence based practice focuses on the implementation of evidence already known into practice Rationale: evidence based practice focuses on the implementation of evidence already known into practice whereas quality improvement measures the effect of changing practices on a specific population. Both evidence based practice and quality improvement are part of regular clinical practices, aim to improve client care and outcomes, consist of internal funding and be conducted by practicing nurses and other healthcare professionals
Which client situation will the nurse address first on priority basis of Maslow's hierarchy of needs?
Has multiple fainting episodes due to lack of proper nutrition Rationale: the basic lower level needs of human beings need to be addressed first before moving to the higher levels. The person physiological needs should be addressed first
Which component of the nursing process includes tasks that can be delegated?
Implementation Rationale: implementation of certain task can be delegated by the RN based on the ability and willingness of the delegatee
Which definition is correct to explain the nursing process?
Sequence of steps used to meet the client's needs Rationale: the nursing process is a step-by-step method that scientifically provides for a clients nursing needs.
The nurse, providing care for a client whose forehead feels warm to the touch, uses a thermometer to obtain the client's temperature. Which action is the nurse taking?
Validation Rationale: validation is the process of gathering more assessment data. It involves clarifying vague or unclear data.
Which scenario would the nurse label as "input component of the nursing process (SATA)
-The nurse checks the clients health history for allergy to iodine before inserting a urinary catheter. -the nurse checks for whether the client has history of substance abuse before administering nasal medications -before placing a internal fecal catheter, the nurse checks the clients ,medical records for any rectilinear surgery within the last year Rationale: the information obtained from a patient's assessment is known as the input component of the nursing process. When the nurse finds that the client urine contains blood after removal of a urinary catheter, or skin changed to bluish purple after applying cold therapy to reduce swelling, this is any example of output component
Which scenario would the nursing consider an example of the feedback component of the nursing process? (SATA)
-The nurse notices that the clients pain has decreased after giving a back massage - the caregiver says the clients body temperature has decreased after administering the prescribed medication -the nurse finds the client has developed breathing issues after administering a medication through the central venous access device. Rationale: the feedback component in the nursing process is the outcome that is reflected by the clients responses to nursing interventions. Content component is advising another assistive personnel to help with something
Which statement would the nurse include when teaching about evidence-based practice
-evidence based practice is conducted by practicing nurses and other health care team members -evidence based practice uses information drawn from research to determine safe and effective nursing care -institutional review board approval is not needed to implement evidence based practice
Which steps listed by the nursing student are accurate regarding discharge planning? (SATA)
-teach the client the safe and effective use of medications and medical equipment -remember that discharge planning is a centralized,coordinated, interdisciplinary process -develop a care plan that moves the client from the hospital to another level of health care Rationale: the nurse would teach the client the safe and effective way use of medications and medical equipment before leaving the health care facilities.
Which information would the registered nurse provide to a student nurse about the importance of nursing? (SATA)
A nurse's documentation ismthe evidence of care that a client receives The nurse would note assessments and significant changes in the client's health Nurses would always document the primary health care providers' responses whenever they are contacted.
Which action would the nurse take to evaluate whether interventions have been effective in treating a clients exertions dyspnea
Ask client about shortness of breath with various activities Rationale: because dyspnea is subjective , the nurse will need to ask the client about whether dyspnea has improved. Auscultation of breath sounds provides objective information on whether problems like pneumonia or asthma have improved.
The nurse is explaining the nursing process to a student. Which step of the nursing process would include interpretation of data collected about the client?
Assessment
The nurse is interviewing a client for admission to the hospital. Which phase of the nursing process is being used in the situation?
Assessment
Which step of the nursing process involves the nurse interviewing a client about a current health problem and obtaining the clients vital sign
Assessment
The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. Which is the purpose of the nurse's action?
Data collection Rationale: the nurse is gathering objective data to support subjective data. The clients report of difficulty breathing is subjective that must be supported by data obtained during the physical examination. The nurse reviews the database after data collection to decide if it is accurate or complete.(data validation). The grouping of data that forms a pattern is called data clusters. The nurse uses critical thinking to interpret the data and analyze it before it is classified and organized into data clusters.
The nurse's coworker approaches the nurse to inquire about the test results of a friend whines being cared for by the nurse. Which response by the nurse would be correct?
Decline to discuss the friends medical condition
The nurse witnesses a visitor have a syncopal episode and collapse on the floor. After providing initial care, maintaining the visitors, safety and providing report to the charge nurse , which action would the nurse take next?
Document the incident
To meet the criteria of ethical practice, which action would the nurse who witnessed the spouse of a client fall take?
Initiate an agency incident report. Rationale: health care agencies document the occurrence of any event out of the ordinary that results in or has the potential to harm a client, employee, or visitor
The registered nurse is teaching the student nurse about writing nursing interventions. Which intervention written by the student nurse indicates effective learning?
Irrigate the wound with 100 mL normal saline until clear: 6 AM—2 PM—8 PM." Rationale: the nursing intervention "irrigate the wound with 100 mL normal saline..." is specific to indicate the quantity of fluid required and also the frequency of the nursing action. The intervention turn the client every two hours doesn't specify the time to change position or the name of the position. Perform blood glucose... does not indicate the frequency to perform blood glucose measurements. Intervention change clients dressing once a shift... does not mention details about method to be used.
Which nursing actions reflects the evaluation phase of the critical thinking process?
Looking at all the situations objectively Using several criteria to determine the effectiveness of a nursing intervention Rationale: the nurse would look at the situations objectively to identify client responses to intervention. The results of the nursing actions should be evaluated using criteria such as expected outcome,pain characteristics, and learning objectives
Which record may the nurse use to document information specific to the clients health in a story like formate?
Narrative documentation
Which client assessment finding would the nurse document as subjective data?
Pain rating of 5 Rationale: subjective data obtained directly from a client.
Which action would the nurse take first when caring for a postoperative client who reports pain?
Perform a focused assessment of the client.
Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?
Planning Rationale: The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client's problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.
When aligning the nursing process to a system, which component is content ?
Product and information obtained from the system
The nurse documents data that was gathered during an assessment in a clients medical record. Which action would the nurse take to ensure that the data is meaningful to other health care providers?
Record objective information using accurate terminology Rationale: the nurse would document all objective information using accurate terminology. The nurse would pay attention tot he facts and report findings exactly as seen,felt, or smelled. If information isn't specific another nurse may gather her own general impressions. Record subjective in quotations exactly as describe by the client.
Which action by the nurse leader signifies the implementation phase of the nursing process as it relates to client teaching
Sequence different task Rationale: implementation involves sequencing of different task. Establishment of expectation occur in planning phase, evaluation phase, the progress is compared with the plan.
Which written statement made the nurse while documenting factual records indicate a need for additional training?
The client seems restless Rationale: for high quality documentation and reporting, the nurse would refrain from using vague terms such as seem or appears because these are not actual facts.
Which client would have a health promotion nursing diagnosis ?
The client who is willing to take a 30-minute walk daily Rationale : a health promotion nursing diagnosis is a clinical judgment of an individual's desire to increase well-being.
Which objective is the most important prerequisite for measuring health care quality delivered in the hospital?
To collect all the medical records of the hospital
Which re,aged factor would the nurse attach to a nursing diagnosis
Trauma of incision Rationale : the related factor or etiology of a nursing diagnosis is always within the nursing domain.
Which step in the nursing process would involve promoting a safe environment for the client
implementation Rationale: the nurse promote safe environment during the implementation stage of nursing process.
