NUR 152 Exam 1 Block 1 GCC

What are the 5 steps of the nursing process?

-Assessment -Diagnosis -Planning -Implementation -Evaluation

What is the correct formatting of the nursing diagnosis?

-Analyze -Actual problem (evidence it exists) -Potential problem/Risk for-goal is to prevent, priority if safety is an issue -R/T:Related To (cannot be medical dx) -AEB:As evidenced by-s/sx which validate the use of selected NANDA label -Data collection-part of assessment>Observation, Interviewing, and Physical examination; Analysis-determine patient strength/problems>Patient agrees with nurses' identification of issues>Patient motivated for resolution; Verification-making sure that something is working correctly>for example NG tube get X-Ray to verify positioning

Characteristics of the care perspective include the following

-Centrality of the caring relationship -Promotion of the dignity and respect of patients as people -Attention to the particulars of individual patients -Cultivation of responsiveness to others and professional responsibility -A redefinition of fundamental moral skills to include virtues like kindness, attentiveness, empathy, compassion, reliability

What questions should a nurse ask a patient to determine fall risk?

-Have you had any falls in the past year? -Are you unsteady when standing or walking? -Do you have any concerns about falling?

What is the importance of the nursing diagnosis?

-Interpret and analyze patient date -Identify patient strengths/health problems -Formulate and validate nursing diagnoses -Develop a prioritized list of nursing diagnoses -Detect and refer s/sx that may indicate a problem beyond the nurse's expertise

Professionalism

-Need to dress professionally according to facility dress code -Be on time -Treat others (patients, families, & staff) with respect & dignity -Convey a calm, caring attitude -Be sensitive to cultural differences -Follow policies and procedures (P&P), standards of care, and your nursing student handbook. -Ask for help when needed!

What does the acronym RACE stand for?

-Rescue anyone in immediate danger -Activate the fire code and notify the appropriate person -Confine the fire by closing doors and windows -Evacuate patients and other people to a safe area

Name the four types of precautions.

-Standard-precautions for all patients regardless of diagnosis -Contact-precautions for patients suspected of having diseases spread by direct or indirect contact. EX: C-Diff -Droplet-precautions for patients suspected of having diseases spread by droplets. (transmission of particles greater than 5 mcm) EX: Rubella, Mumps, Diphtheria, COVID -Airborne-precautions for patients suspected of having diseases spread by fine particles dispersed by air currents (transmission of particles less than 5 mcm) EX: Tuberculosis, Measles, SARS)

Patient-centered care

-The NOF will provide holistic care. -The NOF values, needs, and respects the patient (or designee) as a full partner in providing care that is: >compassionate >coordinated >age and culturally appropriate >safe and effective

Quality Improvement

-The NOF will use data to monitor the care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. -The ANA defines nurse-sensitive indicators as measures that reflect the structure of nursing care that may be measured by the number, the skill level, and the education/certification of nursing staff.

Leadership

-The Nurse of Future will transform and influence behaviors of individuals and groups to promote, establish, and achieve shared goals determined within their settings. -Nurses will advance within their leadership abilities, in collaborative inter-professional efforts, and for implementing change.

Systems-based practice

-The Nurse of the Future will demonstrate: an awareness of, and responsiveness to, the larger context of the health care system. -the ability to effectively call on microsystem resources to provide care that is of optimal quality and value. (improve safety and quality of patient care)

When do you perform hand hygiene?

1. Before resident/patient contact 2. Before an aseptic task 3. After exposure to blood/body fluids 4. After resident contact 5. After contact with resident surroundings 6. Beginning and end of shift 7. Before and after eating, drinking or smoking 8. Before and after using the bathroom 9. After coughing, sneezing, blowing nose, or touching 10. Before touching clean equipment or linen 11. After exposure to contaminated equipment, soiled linens, or resident surroundings 12. Before passing meal trays 13. After removing disposable exam gloves.

Name the two types of restraints

Chemical and Physical

T/F: The nursing process is linear.

False

What act states that residents have the right to be free of unnecessary drugs and physical restraints?

Federal Nursing Home Reform Act (1987)

What demographic of people are the most at risk for falling?

Older adults and children

Name 3 types of physical restraints

Side rails, geriatric chairs with attached stands, and applications tied at the wrist, ankle or waist

Who determines the nurses scope of practice?

State Boards of Nursing

Teamwork and Collaboration

The NOF will function effectively within nursing and interdisciplinary teams, fostering open communication, mutual respect, shared decision making, team learning, and development.

Evidence-based practice

The NOF will integrate the best evidence available, using nursing expertise and the values and preferences of individuals, families, and communities who are served by health care.

Communication

The NOF will interact effectively with patients, families, and colleagues, fostering mutual respect and shared decision making, to enhance patient satisfaction and health outcomes.

Safety

The NOF will minimize risk of harm to clients and providers through both system effectiveness and individual performance.

Informatics and Technology

The Nurse of the Future will use information and technology to communicate, manage knowledge, mitigate error, and support decision making

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. a-It promotes the patient's sense of well-being. b-It prevents deterioration of the oral cavity. c-It contributes to decreased incidence of aspiration pneumonia. d-It eliminates the need for flossing. e-It decreases oropharyngeal secretions. f-It helps to compensate for an inadequate diet.

a, b, c. Adequate oral hygiene is essential for promoting the patient's sense of well-being and preventing deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal secretions, decreasing the incidence of aspiration pneumonia and other systemic diseases. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition.

A nurse is providing foot care for patients in a long-term care facility. Which actions are recommended guidelines for this procedure? Select all that apply. a-Bathe the feet thoroughly in a mild soap and tepid water solution. b-Soak the feet in warm water and bath oil. c-Dry feet thoroughly, including the area between the toes. d-Use an alcohol rub if the feet are dry. e-Use an antifungal foot powder if necessary to prevent fungal infections. f-Cut the toenails at the lateral corners when trimming the nail.

a, c, e. The following are recommended guidelines for foot care: bathe the feet thoroughly in a mild soap and tepid water solution; dry feet thoroughly, including the area between the toes; and use an antifungal foot powder if necessary to prevent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails.

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. a-Compare bilateral parts for symmetry. b-Proceed in a toe-to-head systematic manner. c-Use standard terminology to report and record findings. d-Do not allow data from the nursing history to direct the assessment. e-Document only skin abnormalities on the patient record. f-Perform the appropriate skin assessment when risk factors are identified.

a, c, f. When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head-to-toe systematic manner, and allow data from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings.

A nurse is teaching a student nurse how to cleanse the perineal area of both male and female patients. What are accurate guidelines when performing this procedure? Select all that apply. a-For male and female patients, wash the groin area with a small amount of soap and water and rinse. b-For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area. c-For male and female patients, always proceed from the most contaminated area to the least contaminated area. d-For male and female patients, use a clean portion of the washcloth for each stroke. e-For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. f-In an uncircumcised male patient, do not retract the foreskin (prepuce) while washing the penis.

a, d, e. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from the least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin (prepuce) while washing the penis.

A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply. a-Wash the skin twice a day with a mild cleanser and warm water. b-Use cosmetics liberally to cover blackheads. c-Use emollients on the area. d-Squeeze blackheads as they appear. e-Keep hair off the face and wash hair daily. f-Avoid sun-tanning booth exposure and use sunscreen.

a, e, f. Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face, and sunbathing should be avoided when using acne treatments. Liberal use of cosmetics and emollients can clog the pores. Squeezing blackheads is always discouraged because it may lead to infection.

A nurse is removing rigid gas-permeable (RGP) contact lenses from the eyes of a patient who is unable to assist with removal. The nurse notices that one of the lenses is not centered over the cornea. What would be the nurse's first action in this procedure? a-Apply gentle pressure on the lower eyelid to center the lens prior to removing it. b-Move the eyelids toward one another to cause the lens to slide out between the eyelids. c-Do not attempt to remove the lens as it should only be removed by an eyecare specialist. d-Have the patient look forward, retract the lower lid, and move the lens down on the sclera.

a. If the lens is not centered over the cornea, the nurse should apply gentle pressure on the lower eyelid to center the lens, gently pull the outer corner of the eye toward the ear, position the hand below the lens to receive it, and ask the patient to blink. Moving the eyelids toward one another to cause the lens to slide out between the eyelids is a later step in the procedure. Having the patient look forward, retracting the lower lid and moving the lens down on the sclera occurs during removal of soft contact lenses. It is not necessary to call in an eyecare specialist unless there is damage to the eye.

When a fire occurs in a patient's room, what would be the nurse's priority action? a-Rescue the patient. b-Extinguish the fire. c-Sound the alarm. d-Run for help.

a. The patient's safety is always the priority. Sounding the alarm and extinguishing the fire are important after the patient is safe. Calling for help, if possible, rather than running for assistance, allows you to remain with your patient and is more appropriate.

Moral agency

ability to behave in an ethical way; to do the ethically right thing because it is the right thing to do

Utilitarian

action-guiding theory of ethics that states that the rightness or wrongness of an action depends on the consequences of the action

Principle-based approach

an approach to bioethics that offers specific action guides

Care-based approach

approach to bioethics that directs attention to the specific situations of individual patients viewed within the context of their life narrative

A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. a-A patient who is taking antibiotics for chronic bronchitis b-A patient diagnosed with type II diabetes c-A patient who is obese d-A patient who has a nervous habit of biting his nails e-A patient diagnosed with prostate cancer f-A patient whose job involves frequent handwashing

b, c, d, f. Variables known to cause nail and foot problems include deficient self-care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity.

A nurse assisting with a patient bed bath observes that an older female adult has dry skin. The patient states that her skin is always "itchy." Which nursing action would be the nurse's best response? a-Bathe the patient more frequently. b-Use an emollient on the dry skin. c-Massage the skin with alcohol. d-Discourage fluid intake.

b. An emollient soothes dry skin, whereas frequent bathing increases dryness, as does alcohol. Discouraging fluid intake leads to dehydration and, subsequently, dry skin.

A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient's personal hygiene? a-When the patient had his or her most recent bath b-The patient's usual hygiene practices and preferences c-Where the bathing fits in the nurse's schedule d-The time that is convenient for the patient care assistant

b. Bathing practices and cleansing habits and rituals vary widely. The patient's preferences should always be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patient's personal hygiene. The availability of staff to assist may be important, but the patient's preferences are a higher priority.

A nurse teaches a patient at home to use clean technique when changing a wound dressing. What would be a consideration when preparing this teaching plan? a-It is the personal preference of the nurse whether or not to use clean technique b-The use of clean technique is safe for the home setting c-Surgical asepsis is the only safe method to use in a home setting d-It is grossly negligent to recommend clean technique for changing a wound dressing

b. In the home setting, where the patient's environment is more controlled, medical asepsis is usually recommended, with the exception of self-injection. This is the appropriate procedure for the home and is not a personal preference or a negligent action.

A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the first action of the nurse following the exposure? a-Report the incident to the appropriate person and file an incident report b-Wash the exposed area with warm water and soap c-Consent to PEP at appropriate time d-Set up counseling sessions regarding safe practice to protect self

b. When a needlestick injury occurs, the nurse should wash the exposed area immediately with warm water and soap, report the incident to the appropriate person and complete an incident injury report, consent to and await the results of blood tests, consent to PEP, and attend counseling sessions regarding safe practice to protect self and others.

A nurse is caring for a 25-year-old male patient who is comatose following a head injury. The patient has several piercings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring for this patient's piercings? a-Do not remove or wash the piercings without permission from the patient. b-Rinse the sites with warm water and remove crusts with a cotton swab. c-Wash the sites with alcohol and apply an antibiotic ointment. d-Remove the jewelry and allow the sites to heal over.

b. When providing care for piercings, the nurse should perform hand hygiene and put on gloves, then cleanse the site of all crusts and debris by rinsing the site with warm water, removing the crusts with a cotton swab. The nurse should then apply a dab of liquid-medicated cleanser to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site or remove the piercings unless it is absolutely necessary (e.g., when an MRI is ordered.)

A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? a-The nurse puts on PPE after entering the patient room b-The nurse works from "clean" areas to "dirty" areas during bath c-The nurse personalizes the care by substituting glasses for goggles d-The nurse removes PPE after the bath to talk with the patient in the room

b. When using PPE, the nurse should work from "clean" areas to "dirty" ones, put on PPE before entering the patient room, always use goggles instead of personal glasses, and remove PPE in the doorway or anteroom just before exiting.

A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? a-Remove gown, goggles, mask, gloves, and exit the room b-Remove gloves, perform hand hygiene, then remove gown, mask, and goggles c-Untie gown waist strings, remove gloves, goggles, gown, mask; perform hand hygiene d-Remove goggles, mask, gloves, and gown, and perform hand hygiene

c. If an impervious gown has been tied in front of the body at the waist, the nurse should untie the waist strings before removing gloves. Gloves are always removed first because they are most likely to be contaminated, followed by the goggles, gown, and mask, and hands should be washed thoroughly after the equipment has been removed and before leaving the room.

he nurse assesses patients to determine their risk for HAIs. Which hospitalized patient would the nurse consider most at risk for developing this type of infection? a-A 60-year-old patient who smokes two packs of cigarettes daily b-A 40-year-old patient who has a white blood cell count of 6,000/mm3 c-A 65-year-old patient who has an indwelling urinary catheter in place d-A 60-year-old patient who is a vegetarian and slightly underweight

c. Indwelling urinary catheters have been implicated in most HAIs. Cigarette smoking, a normal white blood cell count, and a vegetarian diet have not been implicated as risk factors for HAIs.

A nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? a-Add bath oil to the water to prevent dry skin. b-Allow the patient to lock the door to guarantee privacy. c-Assist the patient in and out of the tub to prevent falling. d-Keep the water temperature very warm because older adults chill easily.

c. Safe nursing practice requires that the nurse assist a patient with an unsteady gait in and out of the tub. Adding Alpha Keri oil to the bath water is dangerous for this patient because it makes the tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortably warm at 43° to 46°C. Older adults have an increased susceptibility to burns due to diminished sensitivity.

A nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure? a-Shift the focus of the interaction to the "process of bathing." b-Wash the face and hair at the beginning of the bath. c-Consider using music to soothe anxiety and agitation. d-Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar.

c. The nurse should consider the use of music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. The nurse should wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider other methods for bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing "body sections" one day at a time are other possible options.

A nurse is about to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action? a-Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. b-Cut the gown with scissors to allow arm movement. c-Thread the bag and tubing through the gown sleeve, keeping the line intact. d-Temporarily disconnect the tubing from the IV container, threading it through the gown.

c. Threading the bag and tubing through the gown sleeve keep the system intact. Opening an IV line, even temporarily, causes a break in a sterile system and introduces the potential for infection. Cutting a gown is not an alternative except in an emergency.

A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What should be the nurse's next action? a-Make a recommendation for the patient to see an oral surgeon. b-Report the condition to the primary care provider. c-Gently scrape the oral cavity with a tongue depressor. d-Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa.

d. If the mouth is extremely dry with crusts that remain after oral care provided, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above. The crusts should not be scraped with a tongue depressor.

A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What risk factor would be a priority concern for the nurse when caring for this patient? a-Imbalanced nutrition b-Impaired physical mobility c-Chronic pain d-Infection

d. The priority risk factor in this situation is the possibility of an infection developing in the open skin area. The other risk factors may be potential problems for this patient and may also require nursing interventions after the first diagnosis is addressed.

A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? a-Place the bottle cap on the table with the edges down b-Hold the bottle inside the edge of the sterile field c-Hold the bottle with the label side opposite the palm of the hand d-Pour the solution from a height of 4 to 6 in (10 to 15 cm)

d. To add a sterile solution to a sterile field, the nurse would open the solution container according to directions and place the cap on the table away from the field with the edges up. The nurse would then hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 in (10 to 15 cm).

A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patient's eyes? a-Use hydrogen peroxide on a clean washcloth to wipe the eyes. b-Wipe the eye from the outer canthus to the inner canthus. c-Position the patient on the opposite side of the eye to be cleansed. d-Cleanse the eye using a different section of the cleaning cloth for each stroke until clean.

d. When cleaning the eyes, the nurse should wear gloves during the cleaning procedure, use water or normal saline, and a clean washcloth or compress to clean the eyes. The nurse should dampen a cleaning cloth with the solution of choice and wipe once while moving from the inner canthus to the outer canthus of the eye. This technique minimizes the risk for forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleaning cloth and use a different section for each stroke until the eye is clean.

Moral resilience

developed capacity to respond well to morally distressing experiences and to emerge strong

Two types of ethical problems commonly faced by nurses are

ethical dilemmas and moral distress

Deontologic

ethical system in which actions are right or wrong independent of the consequences they produce

Bioethics

ethics that encompass all those perspectives that seek to understand human nature and behavior, the domain of social science, and the natural world

Virtues

human excellences; cultivated dispositions of character and conduct that motivate and enable us to be good human beings

Morals

like ethics, concerned with what constitutes right action; more informal and personal than the term ethics

Moral distress

occurs when you know the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action

Value system

organization of values ranked along a continuum of importance

Nonmaleficence

principle of avoiding evil

Autonomy

self-determination; being independent and self-governing

Values

set of beliefs that are meaningful in life and that influence relationships with others

Ethical dilemma

situation that arises when attempted adherence to basic ethical principles results in two conflicting courses of action

Ethics

system dealing with standards of character and behavior related to what is right and wrong

Conscientious objection

refusal to participate in certain types of treatment and care based on the fact that these activities violate the nurse's personal and professional ethical beliefs and standards

Read the following scenario and identify the adjective used to describe the characteristics of patient data that are numbered below. Place your answers on the lines provided. -The nurse is conducting an initial assessment of a 79-year-old female patient admitted to the hospital with a diagnosis of dehydration. The nurse (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data. (2) First the nurse asks the patient about the most important details leading up to her diagnosis. Then the nurse (3) collects as much information as possible to understand the patient's health problems; (4) collects the patient data in an organized manner; (5) verifies that the data obtained is pertinent to the patient care plan; and (6) records the data according to facility's policy.

(1) Purposeful: The nurse identifies the purpose of the nursing assessment (comprehensive) and gathers the appropriate data. (2) Prioritized: The nurse gets the most important information first. (3) Complete: The nurse gathers as much data as possible to understand the patient health problem and develop a care plan. (4) Systematic: The nurse gathers the information in an organized manner. (5) Accurate and relevant: The nurse verifies that the information is reliable. (6) Recorded in a standard format: The nurse records the data according to the facility's policy so that all caregivers can easily access what is learned.

Feminist ethics

type of ethical approach that aims to critique existing patterns of oppression and domination in society, especially as these affect women and the poor

Eight ethical considerations that have the greatest weight and relevance in the care of patients, which bridge between ethical principles, an ethics of caring, and the clinical situation

-The Balance between Benefits and Harms in the Care of Patients -Disclosure, Informed Consent, and Shared Decision Making -Norms of Family Life -The Relationship between Clinicians and Patients -The Professional Integrity of Clinicians -Cost Effectiveness and Allocation -Issues of Cultural and/or Religious Variation -Considerations of Power

5 Professional Nursing Values:

1. Altruism: Concern for the welfare & well-being of others (patients, other nurses, healthcare staff). 2. Autonomy: Right to self-determination. (Patient's rights to make own healthcare decisions). 3. Human Dignity: Respect for inherent worth and uniqueness of individuals and populations. (respect for all patients and colleagues.) 4. Integrity: Acting in accordance with an appropriate code of ethics and accepted standards of practice. (Honest and provides care based on an ethical framework that is accepted within the profession) 5. Social Justice: Upholding moral, legal & humanistic principles. (assure equal treatment under the law & equal access to quality healthcare)

Nursing ethics

a subset of bioethics; formal study of ethical issues that arise in the practice of nursing and of the analysis used by nurses to make ethical judgments

In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. a-A patient diagnosed with rubella b-A patient diagnosed with diphtheria c-A patient diagnosed with varicella d-A patient diagnosed with tuberculosis e-A patient diagnosed with MRSA f-An infant diagnosed with adenovirus infection

a, b, f. Rubella, diphtheria, and adenovirus infection are illnesses transmitted by large-particle droplets and require droplet precautions in addition to standard precautions. Airborne precautions are used for patients who have infections spread through the air with small particles; for example, tuberculosis, varicella, and rubeola. Contact precautions are used for patients who are infected or colonized by a multidrug-resistant organism (MDRO), such as MRSA.

The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply. -A patient tells the nurse that she is feeling nauseous. -A patient's ankles are swollen. -A patient tells the nurse that she is nervous about her test results. -A patient complains that the skin on her arms is tingling. -A patient rates his pain as a 7 on a scale of 1 to 10. -A patient vomits after eating supper.

a, c, d, e. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.

A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. a-Providing a bed bath for a patient b-Visibly soiled hands after changing the bedding of a patient c-Removing gloves when patient care is completed d-Inserting a urinary catheter for a female patient e-Assisting with a surgical placement of a cardiac stent f-Removing old magazines from a patient's table

a, c, d, f. It is recommended to use an alcohol-based handrub in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement; before donning sterile gloves prior to an invasive procedure; if moving from a contaminated body site to a clean body site; and after contact with objects contaminated by the patient. Keep in mind that handrubs are not appropriate for use with C. difficile infection.

A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendations of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. a-Basing patient care on continuous healing relationships b-Customizing care to reflect the competencies of the staff c-Using evidence-based decision making d-Having a charge nurse as the source of control e-Using safety as a system priority f-Recognizing the need for secrecy to protect patient privacy

a, c, e. Care should be based on continuous healing relationships and evidence-based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for transparency should be recognized.

A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply. a-Monitoring patient status every hour b-Using intuition to troubleshoot patient problems c-Turning a patient on bed rest every 2 hours d-Becoming a nurse mentor to a student nurse e-Administering pain medication ordered by the physician f-Becoming involved in community nursing events

a, c, e. Standards are the levels of performance accepted and expected by the nursing staff or other health care team members. They are established by authority, custom, or consent. Standards would include monitoring patient status every hour, turning a patient on bed rest every 2 hours, and administering pain medication ordered by the physician. Using intuition to troubleshoot patient problems, becoming a nurse mentor to a student nurse, and becoming involved in community nursing events are not patient care standards.

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. a-The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. b-The nurse uses a binary decision tree for stepwise assessment and intervention. c-The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. d-The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. e-The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. f-The nurse uses a decision tree that provides intense specificity and no provider flexibility.

a, c. A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. a-The nurse carefully removes the bandages from a burn victim's arm. b-The nurse assesses a patient to check nutritional status. c-The nurse formulates a nursing diagnosis for a patient with epilepsy. d-The nurse turns a patient in bed every 2 hours to prevent pressure injuries. e-The nurse checks a patient's insurance coverage at the initial interview. f-The nurse checks for community resources for a patient with dementia.

a, d, f. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.

The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. a-"The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b-"It's hospital policy. I know it must be tiresome, but I will try to make this quick!" c-"I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." d-"We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." e-"We need to check your health status and see what kind of nursing care you may need." f-"We need to see if you require a referral to a physician or other health care professional."

a, e, f. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.

The nurse records a patient's blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading? a-Compare this reading to standards. b-Check the taxonomy of nursing diagnoses for a pertinent label. c-Check a medical text for the signs and symptoms of high blood pressure. d-Consult with colleagues.

a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.

A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating?a-A toddler playing with his 9-year-old brother's construction set b-A 4-year-old eating yogurt for lunch c-An infant covered with a small blanket and asleep in the crib d-A 3-year-old drinking a glass of juice

a. A young child may place small or loose parts in the mouth; a toy that is safe for a 9-year-old could kill a toddler. An infant sleeping in a crib without a pillow or large blanket and a 3-year-old and a 4-year-old drinking juice and eating yogurt are not particular safety risks.

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan? a-Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. b-Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle.Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a front-facing safety seat. c-Children older than 6 years may be restrained using a car seat belt in the back seat.

a. Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. All 50 U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a rear-facing safety seat. Many children older than 6 years should still be in a booster seat.

A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome? a-After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. b-By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself. c-Following physical therapy, patient will begin to gradually participate in walking/running events. d-By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events.

a. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." What would be the instructor's BEST response to this student's diagnosis? a-"Was this diagnosis derived from a cluster of significant data or a single clue?" b-"This early diagnosis will help us manage the problem before it becomes more acute." c-"Have you determined if this is an actual or a possible diagnosis?"d-"This condition is a medical problem that should not have a nursing diagnosis."

a. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. A data cluster is a grouping of patient data or cues that point to the existence of a patient health problem. There may be a reason for the lack of a bowel movement for 2 days, or it might be this person's normal pattern.

A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? a-Perform the focused assessment as this is an independent nurse-initiated intervention. b-Request an order from Jill's physician since this is a physician-initiated intervention. c-Request an order from Jill's physician since this is a collaborative intervention. d-Request an order from the nutritionist since this is a collaborative intervention.

a. Performing a focused assessment is an independent nurse-initiated intervention; thus the nurse does not need an order from the physician or the nutritionist.

A quality-assurance program reveals a higher incidence of falls and other safety violations on a particular unit. A nurse manager states, "We'd better find the people responsible for these errors and see if we can replace them." This is an example of: a-Quality by inspection b-Quality by punishment c-Quality by surveillance d-Quality by opportunity

a. Quality by inspection focuses on finding deficient workers and removing them. Quality as opportunity focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Quality by punishment and quality by surveillance are not quality-assurance methods used in the health care field.

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What would be the student's best response? a-Tell the RN that he or she lacks the technical competencies to change the dressing independently. b-Assemble the equipment for the procedure and follow the steps in the procedure manual. c-Ask another student nurse to work collaboratively with him or her to change the dressing. d-Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.

a. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the care plan. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? a-"You made an inference that she is fine because she has no complaints. How did you validate this?" b-"She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." c-"Sometimes everyone gets lucky. Why don't you try to help another patient?" d-"Maybe you should reassess the patient. She has to have a problem—why else would she be here?"

a. The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? a. 2, 4, 1, 3 b. 3, 1, 4, 2 c. 2, 4, 3, 1 d. 3, 2, 4, 1

a. 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.

A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. a-The nurse formulates nursing diagnoses. b-The nurse identifies expected patient outcomes. c-The nurse selects evidence-based nursing interventions. d-The nurse explains the nursing care plan to the patient. e-The nurse assesses the patient's mental status. f-The nurse evaluates the patient's outcome achievement.

b, c, d. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the nursing care plan. Although all these steps may overlap, formulating and validating nursing diagnoses occur most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.

An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. a-Performing the initial patient assessments b-Making patient beds c-Giving patients bed baths d-Administering patient medications e-Ambulating patients f-Assisting patients with meals

b, c, e, f. Performing the initial patient assessment and administering medications are the responsibility of the RN. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.

A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. a-Removes all jewelry including a platinum wedding band b-Washes hands to 1 in above the wrists c-Uses approximately one teaspoon of liquid soap d-Keeps hands higher than elbows when placing under faucet e-Uses friction motion when washing for at least 20 seconds f-Rinses thoroughly with water flowing toward fingertips

b, c, e, f. Proper hand hygiene includes removing jewelry (with the exception of a plain wedding band), wetting the hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid soap, using friction motion for at least 20 seconds, washing to 1 in above the wrists with a friction motion for at least 20 seconds, and rinsing thoroughly with water flowing toward fingertips.

A nurse is caring for a patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. a-Bronchial pneumonia b-Impaired gas exchange c-Ineffective airway clearance d-Potential complication: sepsis e-Infection related to pneumonia f-Risk for septic shock

b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. a-A nurse sits down with a patient and prioritizes existing diagnoses. b-A nurse assesses a woman for postpartum depression during routine care. c-A nurse plans interventions for a patient who is diagnosed with epilepsy. d-A busy nurse takes time to speak to a patient who received bad news. e-A nurse reassesses a patient whose PRN pain medication is not working. f-A nurse coordinates the home care of a patient being discharged.

b, d, e. Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. a-A patient who is older than 50 b-A patient who has already fallen twice c-A patient who is taking antibiotics d-A patient who experiences postural hypotension e-A patient who is experiencing nausea from chemotherapy f-A 70-year-old patient who is transferred to long-term care

b, d, f. Risk factors for falls include age over 65 years, documented history of falls, postural hypotension, and unfamiliar environment. A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics is also a risk factor, not chemotherapy or antibiotics.

A registered nurse is writing a diagnosis for a patient who is in traction because of multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. a-The nurse uses the nursing interview to collect patient data. b-The nurse analyzes data collected in the nursing assessment. c-The nurse develops a care plan for the patient. d-The nurse points out the patient's strengths. e-The nurse assesses the patient's mental status. f-The nurse identifies community resources to help his family cope.

b, d, f. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? a-Risk for Impaired Skin Integrity b-Related to prescribed bed rest c-As evidenced by d-As evidenced by reddened areas of skin on the heels and back

b. "Related to prescribed bed rest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.

The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? a-The nurse positions a patient in a supine position prior to applying wrist restraints. b-The nurse ensures that two fingers can be inserted between the restraint and patient's ankle. c-The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist. d-The nurse ties an elbow restraint to the raised side rail of a patient's bed.

b. The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle. The patient should not be put in a supine position with restraints due to risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered.

A nurse working in a community health clinic writes nursing diagnoses for patients and their families. Which nursing diagnoses are correctly written as three-part nursing diagnoses? 1.Disabled Family Coping related to lack of knowledge about home care of child on ventilator 2.Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-lb weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height-weight charts 3.Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" 4.Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?" "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?"Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression a.(1) and (3) b.(2) and (4) c.(1), (2), and (3) d.(1), (2), (3), (4), and (5)

b. (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement which blames home health aides for the patient's problem. Statements that may be interpreted as libel or that imply nursing negligence are legally hazardous to all the nurses caring for the patient. Assigning blame in the written record is problematic.

A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? a-Maslow's human needs b-Gordon's functional health patterns c-Human response patterns d-Body system model

b. -Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

A nurse makes a clinical judgment that an African American man in a stressful job is more vulnerable to developing hypertension than a White man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis? a-Actual b-Risk c-Possible d-Wellness

b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis.

A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? a-Actual b-Possible c-Risk d-Collaborative

b. An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions.

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care? a-Administer pain medication. b-Reassess the patient. c-Prepare the equipment. d-Explain the procedure to the patient.

b. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and, if necessary, administer pain medications.

A school nurse is performing an assessment of a student who states, "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? a-Incubation period b-Prodromal stage c-Full stage of illness d-Convalescent period

b. During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of infection during the incubation period, and they are more specific during the full stage of illness before disappearing by the convalescent period.

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? a-"There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" b-"You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." c-"No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." d-"Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

b. Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking.

Nurses use the NIC Taxonomy structure as a resource when planning nursing care for patients. What information is found in this structure?a-Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions b-Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings c-A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention d-A complete list of reimbursable charges for each nursing intervention

b. The NIC Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.

A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? a-Offer the patient 60-mL fluid every 2 hours while awake. b-During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. c-Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20. d-At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day.

b. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60-mL fluid every 2 hours while awake." Correct: "The patient will drink 60-mL fluid every 2 hours while awake, beginning 1/3/20." The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include "know," "understand," "learn," and "become aware."

After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values: a-Quality assurance b-Quality improvement c-Process evaluation d-Outcome evaluation

b. Unlike quality assurance, quality improvement is internally driven, focuses on patient care rather than organizational structure, focuses on processes rather than people, and has no end points. Its goal is improving quality rather than assuring quality. Process evaluation and outcome evaluation are types of quality-assurance programs.

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? a-No problem b-Possible problem c-Actual nursing diagnosis d-Clinical problem other than nursing diagnosis

b. When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.

A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. a-Sixty percent of U.S. fire deaths occur in the home. b-Most fatal fires occur when people are cooking. c-Most people who die in fires die of smoke inhalation. d-Fire-related injury and death have declined due to the availability and use of smoke alarms. e-Fires are more likely to occur in homes without electricity or gas. f-Fires are less likely to spread if bedroom doors are kept open when sleeping.

c, d, e. Of all fire deaths in the United States, 80% occur in the home (Warmack, Wolf, & Frank, 2015). Most fatal home fires occur while people are sleeping, and most people who die in house fires die of smoke inhalation rather than burns. The widespread availability and use of home smoke alarms is considered the primary reason for the significant decline in fire-related injury and death. People with limited financial resources should be asked about how they heat their house because the electricity or gas may have been turned off and space or kerosene heaters, wood stoves, or a fireplace may be the sole source of heat. Bedroom doors should be kept closed when sleeping and monitors used to listen for children.

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. a-A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. b-A nurse consults with a psychiatrist for a patient who abuses pain killers. c-A nurse checks the skin of bedridden patients for skin breakdown. d-A nurse orders a kosher meal for an orthodox Jewish patient. e-A nurse records the I&O of a patient as prescribed by his health care provider. f-A nurse prepares a patient for minor surgery according to facility protocol.

c, d, f. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention.

A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the "concepts" that are being diagrammed in this plan? a-Protocols for treating the patient problem b-Standardized treatment guidelines c-The nurse's ideas about the patient problem and treatment d-Clinical pathways for the treatment of sickle cell anemia

c. A concept map care plan is a diagram of patient problems and interventions. The nurse's ideas about patient problems and treatments are the "concepts" that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patient's situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.

A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? a-The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air b-The nurse places soiled bed linens and hospital gowns on the floor when making the bed c-The nurse moves the patient table away from the nurse's body when wiping it off after a meal d-The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items

c. According to the principles of medical asepsis, the nurse should move equipment away from the body when brushing, scrubbing, or dusting articles to prevent contaminated particles from settling on the hair, face, or uniform. The nurse should carry soiled items away from the body to prevent them from touching the clothing. The nurse should not put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least soiled areas first and then move to the more soiled ones to prevent having the cleaner areas soiled by the dirtier areas.

A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? a-Cognitive b-Psychomotor c-Affective d-Physical changes

c. Affective outcomes pertain to changes in patient values, beliefs, and attitudes. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? a-Impaired gas exchange related to cigarette smoking b-Anxiety related to inability to stop smoking c-Risk for suffocation related to unfamiliarity with fire prevention guidelines d-Deficient knowledge related to lack of follow-through of recommendation to stop smoking

c. Because the patient is not aware that smoking in bed is extremely dangerous, she is at risk for suffocation from fire. The other three nursing diagnoses are correctly stated but are not a priority in this situation.

A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? a-Ask another nurse to hold the hand of the patient and continue setting up the field b-Remove the instrument that was touched by the patient and continue setting up the sterile field c-Discard the supplies and prepare a new sterile field with another person holding the patient's hand d-No action is necessary since the patient has touched his or her own sterile field

c. If the patient touches a sterile field, the nurse should discard the supplies and prepare a new sterile field. If the patient is confused, the nurse should have someone assist by holding the patient's hand and reinforcing what is happening.

The nurse is helping a patient turn in bed and notices the patient's heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? a-Initial planning b-Standardized planning c-Ongoing planning d-Discharge planning

c. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

A nurse uses the classic elements of evaluation when caring for patients: (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting your judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what you are looking for when you evaluate—i.e., expected patient outcomes) Which item below places them in their correct sequence? a-1, 2, 3, 4, 5 b-3, 2, 1, 4, 5 c-5, 2, 1, 3, 4 d-2, 3, 1, 4, 5

c. The five classic elements of evaluation in order are (1) identifying evaluative criteria and standards (what you are looking for when you evaluate—i.e., expected patient outcomes); (2) collecting data to determine whether these criteria and standards are met; (3) interpreting and summarizing findings; (4) documenting your judgment; and (5) terminating, continuing, or modifying the plan.

The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? a-Inform the charge nurse. b-Inform the surgeon. c-Validate the finding. d-Document the finding.

c. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN? a-Allow the UAPs to do the admission assessment and report the findings to the RN. b-Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. c-Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. d-Contact his or her labor representative to report this practice to the state board of nursing.

c. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

A nurse develops a detailed care plan for a 16-year-old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? a-"You know your personal situation better than I do, so I will respect your wishes." b-"If you don't accept these services, your baby's health will suffer."c-"Let's take a look at the plan again and see if we can adjust it to fit your needs." d-"I'm going to assign your case to a social worker who can explain the services better."

c. When a patient does not follow the care plan despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the care plan is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.

The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. Which action by the nurse is appropriate? a-Keep splashes on the sterile field to a minimum b-Cover the nose and mouth with gloved hands if a sneeze is imminent c-Use forceps soaked in a disinfectant d-Consider the outer 1 in of the sterile field as contaminated

d. Considering the outer inch of a sterile field as contaminated is a principle of surgical asepsis. Moisture such as from splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves. Forceps soaked in disinfectant are not considered sterile.

A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately? a-The nurse includes suggestions on how to prevent the incident from recurring. b-The nurse provides minimal information about the incident. c-The nurse discusses the details with the patient before documenting them. d-The nurse records the circumstances and effect on the patient in the medical record.

d. A safety event report objectively describes the circumstances of the accident or incident. The report also details the patient's response and the examination and treatment of the patient after the incident. The nurse completes the event report immediately after the incident, and is responsible for recording the circumstances and the effect on the patient in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. Because laws vary in different states, nurses must know their own state law regarding safety event reports.

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? a-Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. b-By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. c-By 6/19/20, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 in). d-By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills; and (c) is an outcome describing a physical change in the patient.

A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? a-Collaborative problem b-Interdisciplinary problem c-Medical problem d-Nursing problem

d. Altered Health Maintenance is a nursing problem, because the diagnosis describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.

A student nurse is organizing clinical responsibilities for a patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? a-Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. b-Schedule the testing and meal planning first and complete hygiene as time permits. c-Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. d-Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

d. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.

When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack? a-Posttraumatic stress disorders can be expected in most survivors of a terrorist attack. b-The FDA has collaborated with drug companies to create stockpiles of emergency drugs. c-Even small doses of radiation result in bone marrow depression and cancer. d-BLI is a serious consequence following detonation of an explosive device.

d. BLI is a recognized consequence following exposure to an explosive device. The CDC is the federal facility that has collaborated with the pharmaceutical companies to stockpile drugs for an emergency. A high dose of radiation exposure can result in bone marrow depression and cancer. Most survivors of a terrorist event will experience stress and some (possibly one third of survivors) may exhibit posttraumatic stress disorder.

Justice

process that distributes benefits, risks, and costs fairly

Advocacy

protection and support of another's rights

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? 1.Ineffective Coping related to inability to maintain marriage 2.Defensive Coping related to loss of job and economic security 3.Altered Thought Processes related to panic state 4.Decisional Conflict related to placement of parent in a long-term care facility a. (1) and (2) b. (3) and (4) c. (1), (2), and (3) d. (1), (2), (3), and (4)

d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.

Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home? a-Checking to make sure fire alarms are working properly. b-Preventing exposure to temperature extremes. c-Screening for partner or elder abuse. d-Making sure patient rooms are decluttered.

d. Falls among older adults are the most common cause of hospital admissions for trauma, therefore rooms should be free of clutter. Elder abuse, fires, and temperature extremes are also significant hazards for older adults but are not the most common cause of trauma admissions. IPV occurs more frequently in adults as opposed to older adults.

A nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine? a-Explain how to use the telephone. b-Introduce the patient to her roommate. c-Review the hospital policy on visiting hours. d-Explain how to operate the call bell.

d. Knowing how to use the call bell is a safety priority; knowing how to use the phone, meeting the roommate, and knowledge of visiting hours will not necessarily prevent an accidental injury.

A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? -Correct the initial assessment form. -Redo the initial assessment and document current findings. -Conduct and document an emergency assessment. -Perform and document a focused assessment of skin integrity.

d. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.

The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? -Comprehensive -Initial -Time-lapsed -Quick priority

d. Quick priority assessments (QPAs) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.

A student health nurse is counseling a college student who wants to lose 20 lb. The nurse develops a plan to increase the student's activity level and decrease her consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 lb, the student has lost only 1 lb. Which is the BEST nursing response? a-Congratulate the student and continue the care plan. b-Terminate the care plan since it is not working. c-Try giving the student more time to reach the targeted outcome. d-Modify the care plan after discussing possible reasons for the student's partial success.

d. Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the care plan. It would not be appropriate to continue the plan as it is since it is not working, and it is premature to terminate the care plan since the student has not met her targeted outcome. The student may need more than just additional time to reach her outcome.

The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients? a-Only patients with diagnosed infections b-Only patients with visible blood, body fluids, or sweat c-Only patients with nonintact skin d-All patients receiving care in hospitals

d. Standard precautions apply to all patients receiving care in hospitals, regardless of their diagnosis or possible infection status. These recommendations include blood; all body fluids, secretions, and excretions except sweat; nonintact skin; and mucous membranes.

What consideration should the nurse keep in mind regarding the use of side rails for a patient who is confused? a-They prevent confused patients from wandering. b-A history of a previous fall from a bed with raised side rails is insignificant. c-Alternative measures are ineffective to prevent wandering. d-A person of small stature is at increased risk for injury from entrapment.

d. Studies of restraint-related deaths have shown that people of small stature are more likely to slip through or between the side rails. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails. Creative use of alternative measures indicates respect for the patient's dignity and may in fact prevent more serious fall-related injuries. A history of falls from a bed with raised side rails carries a significant risk for a future serious incident.

A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is written correctly? a-"Outcome not met." b-"1/21/20—Patient reports no change in diet." c-"Outcome not met. Patient reports no change in diet or activity level." d-"1/21/20—Outcome not met. Patient reports no change in diet or activity level."

d. The evaluative statement must contain a date; the words "outcome met," "outcome partially met," or "outcome not met"; and the patient data or behaviors that support this decision. The other answer choices are incomplete statements.

A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? a-The nurse collects data to identify health problems. b-The nurse collects data to identify patient strengths. c-The nurse collects data to justify terminating the care plan. d-The nurse collects data to measure outcome achievement.

d. The nurse collects evaluative data to measure outcome achievement. While this may justify terminating the care plan, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process.

A nurse working in a pediatrician's office receives calls from parents whose children have ingested toxins. What would be the nurse's best response? a-Administer activated charcoal in tablet form and take child to the ED. b-Administer syrup of ipecac and take child to the ED. c-Bring the child in to the primary care provider for gastric lavage. d-Call the PCC immediately before attempting any home remedy.

d. The nurse should tell the parents to call the PCC immediately, before attempting any home remedy. Parents may be instructed to bring the child immediately to an emergency facility for treatment. Activated charcoal is considered the most effective agent for preventing absorption of the ingested toxin. It is not recommended for storage or use at home. Activated charcoal can be administered through a nasogastric tube in the ED for serious poisonings after the risks and benefits have been determined. Syrup of ipecac is no longer recommended because vomiting may be dangerous. A toxic substance may prove more hazardous coming up rather than when it was swallowed. Gastric lavage is no longer prescribed routinely for the treatment of ingestion of a toxic substance because it may propel the poison into the small intestine, where absorption will occur. The amount of toxin removed by gastric lavage is relatively small.

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? a-Thank the wife for being present. b-Ask the wife if she wants to remain. c-Ask the wife to leave. d-Ask the patient if he would like the wife to stay.

d. The patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.

An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints? a-Sitting him in a geriatric chair near the nurses' station b-Using the sheets to secure him snugly in his bed c-Keeping the bed in the high position d-Identifying his door with his picture and a balloon

d. This allows the resident to be on the move and be more likely to find his room when he wants to return. The alternative would be to not allow him to wander. Many facilities use this kind of approach. Identifying his door with his picture and a balloon may work as an alternative to restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would probably result in a fall.

Fidelity

keeping promises and commitments made to others

Beneficence

principle of doing good

Code of ethics

principles that reflect the primary goals, values, and obligations of the profession

Values clarification

process by which people come to understand their own values and value system