Unit 3 - Foundations Ch. 2-8 & Ch. 19 (part 2)

Nurses use a five-step process in selecting the best nursing interventions for their patients. Using the five-step process in selecting the best nursing interventions, arrange the list on the left in the correct order of completion on the right. (Enter the number of each step in the proper sequence, do not use commas.) 1). Review the desired outcomes/goals. 2). Identify several actions or interventions. 3). Individualize standardized interventions. 4). Review the nursing diagnosis. 5) Choose the best interventions for the patient.

ANS: 4 1 2 5 3 The following five-step process will assist the nurse in selecting the best interventions: Review the nursing diagnosis, review the desired outcomes/goals, identify several actions or interventions, choose the best interventions for the patient, and finally individualize standardized interventions.

Which intervention by the nurse would be best to motivate a patient newly diagnosed with hypertension to learn about the prescribed treatment plan? a) Explain that when left untreated, hypertension may lead to stroke. b) Ask the patient to let you know when he is ready to learn. c) Encourage the patient to learn about various treatment options. d) Reassure the patient that adhering to the treatment produces a good outcome.

ANS: A A patient newly diagnosed with hypertension may not be motivated to learn because he most likely has not experienced physical symptoms or other outward complications. Therefore, the nurse should motivate the patient by pointing out serious risks to the quality of life if the blood pressure control is not achieved. Although readiness to learn is an important consideration, treatment might be delayed too long if the patient does not appropriately perceive the immediacy of the health risk. Simply encouraging a patient to learn about blood pressure and treatment options might not be suitable motivation to engage in active learning and to comply with prescribed treatment. Reassuring the patient and promising a good outcome by complying with medical treatment is not appropriate. Adhering to medical therapy reduces the risk for stroke and other complications; however, this can't be guaranteed.

The nurse is caring for a 55-year-old male smoker on the medical-surgical unit. The patient states, "I'd really like some help in quitting smoking." As part of her intervention plan she includes a smoking cessation class. What type of intervention is the nurse performing? a) Wellness b) Prevention c) Assessment d) Treatment

ANS: A A smoking cessation class is an example of a health promotion or wellness intervention to promote a client's efforts to achieve a higher level of wellness. Treatment interventions treat disorders, relieve symptoms, and carry out medical orders. Assessment interventions detect changes in the client's condition and detect potential problems. Prevention interventions are used to help prevent complications.

Which of the following is the best example of a well-written nursing order? a) Administer pain medication 30 minutes prior to physical therapy exercises. b) Teach patient how to give insulin injections prior to discharge. c) The nurse will assess vital signs and report changes as needed. d) Consider patient and family cultural preferences in diet order.

ANS: A A well-written nursing order includes date, subject, action verb, time frame, limits, and a signature. The best example is the nursing order to administer pain medications within 30 minutes prior to physical therapy. This example provides the most information and direction for the nurse as it contains the subject, action verb, time frame, and limits. The remaining options do not provide enough direction and information for the nurse as they are vague and nonspecific.

A nurse researcher is designing a research project. After identifying and stating the problem, the nurse researcher clarifies the purpose of the study. Which step in the research process should she complete next? a) Perform a literature review b) Develop a conceptual framework c) Formulate the hypothesis d) Define the study variables

ANS: A After identifying and stating the problem, the nurse researcher should clarify the purpose of the study. Next, the researcher should perform a literature search to find out what is already known about the problem. After the literature search, the researcher should choose a conceptual framework to guide the research, formulate the hypothesis or research question, and define the study variables.

The nurse researcher is conducting a study. In preparation for the study, she will be developing a method for participants' identification while securing their privacy and confidentiality. What is the best method the researcher can use for participant identification and securing privacy and confidentiality? a) Use a code number for each participant b) Use participant initials only c) Use gender and age only d) Use participant surname only

ANS: A All participants have the right to have their identification protected. Generally, they are given a code number rather than being identified by name. Once the study is completed and the data are analyzed, the researcher is responsible for protecting the raw data (such as questionnaires and taped interviews).

While reading a journal article, the nurse asks herself these questions: "What is this about overall? Is it true in whole or in part? Does it matter to my practice?" What is this nurse doing? a) Reading the article analytically b) Performing a literature review c) Formulating a searchable question d) Determining the soundness of the article

ANS: A Analytical reading involves questioning the article to be sure you understand it and to determine whether it is applicable to your practice. Such reading asks these questions: "What is this about as a whole? Is it true in whole or in part? Does it matter to my practice?" A literature review is performed by searching indexes and databases, and reading more than one article. Formulating a searchable question involves creating a PICO-type statement to guide a search of the literature. The nurse would determine whether the article is a research report by looking for the individual parts of the article to see if they were present in the form of research (e.g., title, problem, hypothesis, purpose, methods, data, data analysis, conclusions).

The nurse reviews the patient chart and sees a physician prescription for a new medication. The nurse is able to clearly read the medication name but the dose is not legible. What is the best action by the nurse? a) Contact the physician for clarification. b) Ask another nurse to read the order. c) Ask the unit secretary to read the order. d) Contact the pharmacist to read the order.

ANS: A As a nurse, you are obligated ethically and legally to clarify or question orders that you believe to be unclear, incorrect, or inappropriate. In this case, the nurse should contact the physician to clarify the order, as it is not legible. It is inappropriate to ask the secretary or another nurse to read the order as they may read it incorrectly.

A physician orders an indwelling urinary catheter for a client who is mildly confused and has been combative. How should the nurse proceed? a) Ask a colleague for help, because the nurse cannot safely perform the procedure alone. b) Gather the equipment and prepare it before informing the client about the procedure. c) Obtain an order to restrain the client before inserting the urinary catheter. d) Inform the primary provider that the nurse cannot perform the procedure because the client is confused.

ANS: A Before the nurse begins a procedure, she should review the care plan and look at the orders critically. Because this client is confused, she should ask a colleague to assist with the procedure to prevent undue stress for the client and nurse. The client should be informed about the procedure before the nurse gathers the equipment. Gathering the equipment and bringing it into the room before explaining the procedure might cause the client anxiety. Restraining the client should be done only as a last resort and to prevent client injury. Informing the primary provider that the procedure cannot be performed because the client is confused is inappropriate because the procedure can very likely be done with assistance.

Which statement accurately describes delegation? a) Transferring authority to another person to perform a task in a selected situation b) Collaborating with other caregivers to make decisions and plan care c) Scheduling treatments and activities with other departments d) Performing a planned intervention from a critical pathway

ANS: A Delegation is the transfer to another person of the authority to perform a task in a selected situation—the person delegating retains accountability for the outcome of the activity. Collaboration is described as working with other caregivers to plan, make decisions, and perform interventions. Coordination of care involves scheduling treatments and activities with other departments. Implementation is the process of performing planned interventions.

A client is admitted to the hospital with an acute respiratory problem resulting from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations. Which nursing intervention should be listed first on the care plan? a) Determine airway adequacy hourly and as needed. b) Administer oxygen as needed. c) Monitor arterial blood gas values. d) Place the client in a high Fowler's position.

ANS: A For any acute respiratory problem, prior to implementing interventions the nurse would assess breathing status of the patient by checking the respiratory rate and depth. When devising a plan of care for the client, nursing interventions should be listed according to priority. Airway always takes precedence, as ventilation, oxygenation, and positioning will be ineffective without a patent airway.

Prior to discharge, a patient with diabetes needs to learn how to check a finger-stick blood sugar reading before taking insulin. Which action will best help the patient remember proper technique? a) Encouraging the patient to check the blood sugar each time the nurse gives insulin b) Providing feedback after the patient takes his blood sugar reading for the first time c) Verbally instructing the patient about how to obtain a finger-stick blood sugar reading d) Offering a brochure that describes the technique for checking a blood sugar reading

ANS: A Having the patient perform a finger stick with the nurse each time insulin is administered is the best way to practice the correct technique and gain confidence prior to discharge. Repetition increases the likelihood that the patient will retain information and incorporate it into the daily management of his diabetes care. Although feedback is important, the patient might need it on more than one occasion. Verbal instructions for performing a new skill are most useful when the patient has an opportunity to perform the technique. A brochure is informative and useful for later reference; however, information about performing a new skill is best offered when the patient can see it demonstrated and has the opportunity to practice it with the feedback from the nurse.

In his later work, Maslow identified growth needs that must be met before reaching self-actualization. These needs include: a) Cognitive and aesthetic needs b) Love and belonging needs c) Safety and security needs d) Physiological and self-esteem needs

ANS: A In his later work, Maslow identified two growth needs that must be met before reaching self-actualization. They include cognitive (to know, understand, and explore) and aesthetic (for symmetry, order, and beauty) needs. The needs Maslow identified in his earlier work were physiological, safety and security, love and belonging, esteem, and self-actualization.

The nurse enters a patient's room and notes he is nauseous, vomiting, and experiencing abdominal pain, and has no bowel sounds. She concludes that the patient's symptoms may be associated with a paralytic ileus. In arriving at this conclusion, the nurse has used: a) Inductive reasoning b) Deductive reasoning c) Guesswork d) Diagnostics

ANS: A Inductive reasoning is often used in the nursing process. Induction moves from the specific to the general. One gathers separate pieces of information, recognizes a pattern, and forms a generalization or conclusion. In this item, the nurse uses inductive reasoning based on her observations and assessment of this patient and concludes his symptoms are associated with a paralytic ileus. This is not guesswork, as the nurse is using her observation, assessment skills, and knowledge to draw a conclusion. Deductive reasoning starts with a general premise and moves to a specific deduction. The nurse is not diagnosing this patient, as this is the scope of practice for the medical doctor. She is, however, making an association between S+S and a disease process.

Which type of client-centered evaluation is performed at specific, scheduled times? a) Intermittent b) Ongoing c) Terminal d) Process

ANS: A Intermittent evaluation is performed at specific times; it enables the nurse to judge the progress toward goal achievement and to modify the plan of care as needed. Ongoing evaluation is performed while implementing, immediately after an intervention, or with each client contact; these are not necessarily scheduled events. Terminal evaluation is performed at the time of discharge. It describes the client's health status and progress toward goals at that time. Process evaluation focuses on the manner in which care is given. It may be performed at specific times, but it is not considered a client-centered evaluation.

Which commonly accepted practice came out of the Framingham study? Use of: a) Mammography in breast cancer screening b) Colonoscopy in colon cancer screening c) Pap testing in cervical cancer screening d) Digital rectal examination in prostate cancer screening

ANS: A One commonly accepted practice that came out of the Framingham study is the link between mammography and breast cancer. Before the Framingham study, mammography was considered an unreliable tool in breast cancer screening.

A patient with attention deficit disorder is admitted to the hospital with type 1 diabetes. Which nursing diagnosis is commonly yet inappropriately used but should be avoided for this type of patient? Assume there are data to support all the diagnoses. a) Deficient Recall (disease process) b) Impaired Ability to Learn related to Fear and Anxiety c) Difficulty Learning related to Cognitive Developmental Level d) Lack of Motivation to Learn related to Feelings of Powerlessness

ANS: A Patients who have a learning disability should not have an identified nursing diagnosis of Deficient Recall; instead, they should have a diagnosis that accurately identifies their problem, such as Impaired Ability to Learn related to Fear and Anxiety; Difficulty Learning related to Cognitive Development Level; or Lack of Motivation to Learn related to Feelings of Powerlessness. Note that these are not NANDA-I diagnoses.

The nurse knows that iron deficiency anemia is caused by low levels of iron in the body that can be improved by a diet high in iron. Based on this information, the best nursing diagnosis is: a) Imbalanced nutrition: less than body requirements for iron r/t possible Deficient Recall of dietary needs b) Deficient Recall r/t imbalanced nutrition due to less than body requirements of iron c) Imbalanced nutrition: less than body requirements r/t inability to access information d) Inability to access information r/t Deficient Recall about dietary needs for iron

ANS: A The best use of the diagnosis of deficient knowledge is as a secondary diagnosis related to the primary diagnosis. Here, the primary nursing diagnosis is Imbalanced nutrition: less than body requirements of iron (supported by presence of iron deficiency anemia). This may well be caused by lack of knowledge about iron-rich foods, but there are no data to support that. Therefore, the etiology must be "possible Deficient Recall." Deficient Recall should be used only as a primary diagnosis if that is the cause of the iron deficiency anemia. There is insufficient information in the question to make this the primary diagnosis. There is not sufficient information to support the diagnoses of Imbalanced nutrition: less than body requirements r/t inability to access information and Inability to access information r/t Deficient Recall about dietary needs for iron; we have no data about the patient's access to information for a low iron diet.

Which task can be delegated to nursing assistive personnel (NAP)? a) Turn and reposition the patient every 2 hours. b) Assess the patient's skin condition. c) Change pressure ulcer dressings every shift. d) Apply hydrocolloid dressing to the pressure ulcer.

ANS: A The nurse can delegate turning the client every 2 hours to the nursing assistive personnel. Assessing the client's skin condition, changing pressure ulcer dressings, and applying a hydrocolloid dressing to a pressure ulcer are all interventions that require nursing knowledge and judgment.

The nurse is using electronic care planning. He enters the patient's nursing diagnosis into the computer and chooses desired outcomes. He has validated his data, diagnosis, and goals. When he considers the list of interventions that the program generates, he sees that none of them fits this patient's individual needs. What should the nurse do? a) Reject them all and type in appropriate interventions. b) Select the interventions from the program that are most suitable. c) Ask another nurse to assess the patient and give her recommendation. d) Restart the computer; it is probably a program malfunction.

ANS: A The nurse can reject all the suggested interventions if they do not address patient needs. Nearly all computer programs have a screen that allows you to type in interventions and nursing orders. It is the nurse's responsibility to choose interventions: He cannot abdicate this responsibility and let the computer "choose." As a professional, this nurse has already validated the data, nursing diagnosis, and goals, so he can feel reasonably certain that there is nothing wrong with the plan to that point. Although consultation with other nurses may be a wise and prudent step to take at times, the nurse caring for the patient would likely have the most familiarity with the healthcare needs and is in a better position to make sound judgments than another nurse who does not know the patient. Therefore, it might not be productive or efficient to consult another nurse or restart the computer.

Who is responsible for evaluating the outcome of a task delegated to the nursing assistive personnel (NAP)? a) Nurse who delegated the task b) LPN working with the NAP c) Unit nurse manager d) Charge nurse for the shift

ANS: A The nurse who delegates the task is responsible for supervising and evaluating the outcomes of tasks performed by the NAP. Another registered nurse, such as a staff nurse, nurse manager, or charge nurse, can answer questions and provide help, if necessary.

A preschool-age child is scheduled for a tonsillectomy. Which strategy might help lessen the child's anxiety before surgery? a) Show the child a short, animated video (DVD) about the hospital visit and procedure. b) Give the child a tour of the hospital a week before the surgery is scheduled. c) Allow the child to use online sources of information to teach him about the procedure. d) Provide one-to-one instruction about the care he will need after surgery.

ANS: A To reduce anxiety in a preschool-age child requiring surgery, show a short, animated video showing the area of the hospital where the child will be. The video should include a simple explanation of what is going to happen while he is in the hospital and afterward in a manner that is upbeat and friendly. A tour of the hospital with the sights and smells of sicker people might be more frightening to the young child. It is best to avoid exposure to pathogens before surgery, such as what could be acquired when touring the building. One-to-one instruction and online sources of information are teaching strategies for adults and older children.

Which of the following best describe the primary goal(s) of evidence-based practice? Select all that apply. a) Identify the most effective treatments for disease processes, conditions, or problems b) Identify the most cost-effective treatments for disease processes, conditions, or problems c) Include all patient and family preferences in guiding nursing practice d) Create standardized clinical pathways for healthcare organizations

ANS: A, B Evidence-based practice (EBP) is an approach that uses firm scientific data rather than anecdote, tradition, intuition, or folklore in making decisions about medical and nursing practice. In nursing, it includes blending clinical judgment and expertise with the best available research evidence and patient characteristics and preferences. The goal of EBP is to identify the most effective and cost-effective treatments for a particular disease, condition, or problem. In using EBP, the nurse considers patient preferences; however, this is not the goal of EBP.

The nurse is selecting nursing interventions for her patient with diabetes. The nurse will select interventions using which resources available to her? Select all that apply. a) A standardized list of interventions b) Interventions generated based on her knowledge base and past experiences c) Traditional interventions that seem to have worked in the past d) Only those interventions that agree with patient preferences

ANS: A, B In selecting nursing interventions, a nurse has many resources available to her. One can select from a standardized list such as the NIC, standardized care plans, agency protocols, nursing texts, journals, and other professional nurses. Additionally, a nurse can generate her own list of interventions based on her knowledge base and experience. When possible, it is always best to choose interventions based on research and scientific principle. Traditional interventions can be used but they should be interventions that are supported by research as opposed to "seeming" to have worked. Patient preferences and directions are always considered when possible; however, the nurse cannot use only those interventions based on patient direction and preference.

Which of the following statement(s) best describe(s) nursing research? Select all that apply. a) Nursing research is a systematic, objective process of analyzing phenomena important to nursing. b) The purpose of nursing research is to develop knowledge about issues important to nursing. c) Nursing research is an organized set of related ideas and concepts that build principles and theories. d) All data in the research process are reported in numbers to make generalizations about specific populations.

ANS: A, B Nursing research is the systematic, objective process of analyzing phenomena of importance to nursing. Its purpose is to develop knowledge about issues that are important in nursing. An organized set of related ideas and concepts is a theory. Data reported in numbers is a quantitative research design used in nursing research however not all nursing research is quantitative research. Much of nursing research can be qualitative as well.

Which of the following is the most appropriate task(s) to be delegated to the licensed practical nurse (LPN)? Select all that apply. a) Administer oral pain medications b) Insert an indwelling (e.g., Foley) catheter c) Perform an admission assessment on a new patient d) Establish a new teaching plan for a diabetic patient

ANS: A, B The licensed practical nurse (LPN) can administer oral medications and insert a Foley catheter. LPNs can usually provide care to medically stable patients according to an established plan of care; they can give you feedback about patient responses for patients who are expected to respond predictably. Tasks you can usually assign to an LPN include administering some medications and oral medications, and in some instances, starting an IV infusion and administering plain IV solutions. Some tasks that cannot be delegated include creating or modifying nursing care plans. Performing an admission assessment on a newly admitted patient and establishing a teaching plan are usually the responsibility of the registered nurse, as these tasks requires professional nursing judgment and critical thinking.

The American Nurses Association (ANA) has set standards for registered nurses in utilizing evidence-based interventions and treatments in practice. According to the ANA, which of the following statement(s) best describes these standards? Select all that apply. The registered nurse: a) Uses current evidence-based nursing knowledge to guide practice decisions b) Critically analyzes evidence-based practice and research findings for application to practice c) Shares research activities and findings with peers and others d) Uses specific competencies in conducting and integrating research

ANS: A, B, C According to the ANA Standards of Professional Performance (standard 9) concerning evidence-based practice, there are two main criteria: The registered nurse uses current evidence-based nursing knowledge, including research findings, to guide practice decisions, critically analyzes evidence-based practice and research findings for application to practice, participates in the development of evidence-based practice through research activities, and shares research activities and/or findings with peers and others. Competencies related to research are stated by QSEN under its educational competencies and are not part of the ANA standards.

The nurse has completed the plan of care for her patient with a medical diagnosis of Gall Bladder Disease. In selecting nursing interventions that will best serve to help the patient achieve the desired goals, the nurse will consider which of the following? Select all that apply. a) Age of the patient b) Patient abilities and preferences c) Education levels of the nursing staff d) Medical orders

ANS: A, B, C, D Nursing interventions are formulated to assist the patient in achieving the desired goals. In doing so, the nurse must consider patient abilities and preferences, the education, experience, and capabilities of the nursing staff, the resources available, medical orders, and institutional policies and procedures: Therefore all options are applicable.

The nurse is giving you the shift report. She states the client's diagnoses, treatments, and course of hospitalization. When describing the client she states, "Whenever I try to teach him something, he becomes difficult and argumentative." What client information about patient teaching should you ask? Select all that apply. a) Level of literacy b) Primary language c) Need for humor d) Level of anxiety e) Questions answered

ANS: A, B, D, E If using print-based materials for patient teaching, the nurse would need to know the patient's literacy level and make sure information is presented at the appropriate reading level. The nurse must be aware of language comprehension to communicate effectively with the client. The nurse might plan to use various tools for translation, if language proficiency is a problem. When the nurse starts teaching, the client shows his anxiety about the health topic by his difficult and argumentative behavior. As level of client anxiety can be a barrier to learning, the nurse must assess anxiety and stress to make sure the teaching is done at a time of the lowest levels of anxiety and stress. Assessment of whether the client's questions were answered in his primary language to ensure understanding is very important for the nurse to know. Humor should not be used, especially in a second language for the nurse, as it may be misinterpreted or misunderstood.

The nurse has just completed wound care on her patient who has a large abdominal wound. What should the nurse do soon after this is completed? Select all that apply. a) Assess the patient's response to the procedure b) Teach the patient about the procedure c) Document the procedure in the nursing progress notes d) Ask the patient to assist in the wound care at the next scheduled dressing change

ANS: A, C After giving care, the nurse needs to assess and record the nursing activities and the patient's responses. This is the final step in the implementation process. Documentation is a mode of communication among the members of the health team, so it needs to be done soon after finishing the procedure. It provides the information the nurse needs to evaluate the patient's health status and nursing care plan. The implementation phase ends when the nurse documents the nursing actions and evolves into evaluation as the nurse documents patient responses to the interventions. Teaching the patient and asking the patient to assist in wound care as a part of that teaching do not need to be done right away.

Which statement(s) about nursing interventions is/are true? Select all that apply. a) The responsibility of writing nursing orders cannot be delegated to the LPN/LVN. b) The best nursing interventions are based on tradition. c) Nursing interventions should be individualized and culturally sensitive. d) Standardized nursing interventions improve care for a specific client.

ANS: A, C Some nursing interventions and activities can be delegated to the LPN/LVN or nursing assistive personnel (NAP); however, writing nursing orders is the responsibility of the registered nurse. Nursing interventions should always be individualized and culturally sensitive. Whenever possible, nursing interventions should be based on scientific evidence, not tradition. Standardized interventions are not customized to improve care for a specific client.

The nurse and nursing assistive personnel (NAP) are caring for a group of patients on the medical-surgical floor. For which of the following patients can the nurse delegate to the NAP the task of bathing? Select all that apply. a) 75-year-old patient newly admitted with dehydration b) 65-year-old patient hospitalized for a stroke, whose blood pressure reading is 189/90 mm Hg c) 92-year-old patient with stable vital signs who was admitted with a urinary tract infection d) 56-year-old patient with chronic renal failure who has vital signs within his normal range

ANS: A, C, D The nurse should not delegate bathing of a client newly diagnosed with a stroke whose blood pressure is unstable or otherwise abnormal. This client requires the keen assessment and critical thinking skills of a registered nurse. The nurse can safely delegate the care of stable clients, such as the client admitted with dehydration, the client admitted with a urinary tract infection, or the client with chronic renal failure. Any client who is very ill or who requires complex decision making should be cared for by a registered nurse.

Which of the following is a client outcome criterion? a) Central venous catheter site infection does not occur (90% of cases). b) Client will sit out of bed in the chair for 20 minutes three times per day. c) Postoperative phlebitis does not occur (95% of cases). d) Falls in the facility will reduce by 2% this quarter.

ANS: B A client outcome criterion states the client health status or behaviors one wishes to effect. "Client will sit out of bed . . ." is a client outcome criterion. The other options are examples of organizational criteria used to evaluate the quality of care throughout the institution.

A patient complains of pain after undergoing surgery. The nurse forms a mental image of pain based on her own experiences with pain. This mental image is known as a(n): a) Phenomenon b) Concept c) Assumption d) Definition

ANS: B A concept is a mental image of a phenomenon, an aspect of reality that you can observe and experience. In the scenario above, the nurse forms a mental image of pain because of her past experiences with pain. Phenomena are the subject matter of a discipline. They mark the boundaries of a discipline. An assumption is an idea that is taken for granted. In a theory, the assumption is the idea that the researcher presumes to be true and does not intend to test with research. A definition is a statement of meaning of a term or concept that sets forth the concept's characteristics or indicators.

Which of the following is the most valid criterion for determining the status of a patient's anxiety at discharge? The patient: a) Has a relaxed facial expression b) Reports that he feels more relaxed today c) Shows no physiological signs of anxiety (e.g., pallor) d) Asks no further questions about home care

ANS: B A criterion is considered valid when it measures what it is intended to measure. Because anxiety is subjective (perceived by the patient), the best measure of anxiety is what the patient says about it. A relaxed facial expression and other physiological signs might or might not show the level of anxiety. Relaxation might occur, for example, because the patient is sleeping or falling asleep. The fact that a patient is not asking questions about his surgery could mean that he has adequate knowledge about the topic; it would not indicate the presence or absence of anxiety. All of the options except what the patient states could be measuring something other than anxiety.

After suffering an acute myocardial infarction, a patient attends cardiac rehabilitation. This will help to gradually build his exercise tolerance. According to Maslow's Hierarchy of Needs, cardiac rehabilitation most directly addresses which need? a) Safety and security b) Physiological c) Self-actualization d) Self-esteem

ANS: B Cardiac rehabilitation most directly addresses the patient's physiological need for physical activity as well as for health and healing. Indirectly, of course, better physical condition might enable the patient to perform activities that would lead to higher self-esteem and even self-actualization.

The nurse works with the respiratory therapist to administer a patient's breathing treatments. He reports the patient's breathing status and tolerance of the treatment to the primary care provider. The nurse then discusses with the patient the options for further treatment. This is an example of: a) Delegation b) Collaboration c) Coordination of care d) Supervision of care

ANS: B Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain "the big picture." Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity or task.

The nurse is completing her plan of care for a patient with congestive heart failure. In performing a direct-care nursing intervention the nurse will: a) Collaborate with the physician for further medication orders b) Instruct the patient about low sodium and low fat diets c) Refer the patient to the cardiac rehabilitation program for a home-care exercise program d) Consult with physical therapist for cardiac rehabilitation exercises

ANS: B Direct-care interventions are performed through interactions with the client. Examples are physical care, emotional support, and teaching. An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocating, and managing the environment.

Which of the following nursing activities is most reflective of the evaluation phase of the nursing process? a) Administering pain medication prior to changing a complex wound dressing b) Obtaining patient's blood pressure 30 minutes after administering blood pressure medication c) Reporting that there have been three patient falls in the past month on the nursing unit d) Teaching the patient how to perform daily Accu-Cheks for blood sugar readings

ANS: B Evaluation is the final step of the nursing process. It is a planned, ongoing, systematic activity in which a nurse will make judgments about patient progress toward desired health outcomes, effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting. Evaluation data are collected after interventions are performed to determine whether patient goals were achieved. In this item, obtaining a patient's blood pressure after administering blood pressure medications evaluates the patient's response to the medication. Administering pain medication prior to performing a dressing change is an intervention, as is teaching a patient to perform an Accu-Chek. Reporting patient falls is part of the assessment process.

Which of the following best describes evidence-based practice? a) Tool developed by a healthcare organization for its own use to guide best nursing practice b) An approach that uses the best scientific data to guide nursing practice c) Nurses who uses clinical judgment and expertise to guide nursing practice d) A method of practice that uses tradition and folklore interventions to guide practice

ANS: B Evidence-based practice is an approach that uses firm scientific data rather than anecdote, tradition, intuition, or folklore in making decisions about medical and nursing practice. In nursing, it includes blending clinical judgment and expertise with the best available research evidence and patient characteristics and preferences. A tool developed by a healthcare organization is usually in the form of a clinical pathway. These pathways are usually written per research evidence but not always.

A patient with a diabetic foot ulcer will need to perform dressing changes after discharge. When should the nurse schedule the teaching session(s)? a) Within 10 minutes after his next dose of oral pain medication b) After the patient wakes up from a restful nap c) Before the surgeon debrides the wound d) Before the patient undergoes flow studies of his affected leg

ANS: B For learning to be most effective, teaching must occur when the patient is most receptive. A patient's capacity to take in new information is reduced when he is anxious, in this example about testing or treatment, or is tired, or experiencing pain. Therefore, the best time to teach this patient is when he is rested, such as after a restful nap. Ten minutes is not enough time for oral medication to take effect and relieve pain.

The nurse is preparing to insert a Foley catheter for her patient. What is the best strategy for the nurse to use to perform this insertion in a timely and efficient manner? a) Call another nurse to assist with the procedure b) Gather all supplies and equipment before entering the patient room c) Instruct and explain the procedure to the patient d) Check the patient's schedule for the day for the most convenient time

ANS: B Gathering all the supplies and equipment before entering a patient's room is the best strategy to ensure that work is completed in an efficient and timely manner. This strategy will also help in preventing stress to the patient that may occur when a nurse is interrupted by needing to go to a supply room to get a needed item. Healthcare resources are scarce and staffing may not be conducive or feasible in having extra personnel available. Instructing and explaining a procedure to a patient is good practice and usually completed prior to any procedure for the purpose of patient cooperation and understanding. This is will not usually assist the nurse in completing a procedure in an efficient and timely manner.

A client is admitted to the hospital with an acute episode of chronic obstructive pulmonary (lung) disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related to inability to maintain adequate rate and depth of respirations and has recorded the diagnosis and appropriate goals on the care plan. When selecting nursing interventions, what should the nurse do first? a) Identify several interventions likely to achieve the desired outcomes. b) Review the problem and etiology of the nursing diagnosis. c) Choose the best interventions for the patient. d) Review the goals she has written.

ANS: B The process of choosing interventions is first to review the nursing diagnosis and etiology; then review the desired outcomes; identify several interventions or actions; choose the best interventions for the patient; and then individualize standardized interventions to meet the patient's unique needs.

Which statement by the patient demonstrates health literacy? a) "I speak and understand little English but will do what I am told." b) "I will take my medications after I ask the nurse a few questions." c) "I have not taken my prescribed antibiotics because I can't read the labels." d) "I stopped my medications when I started feeling better."

ANS: B Health literacy is the ability to understand basic health information and services needed to make appropriate healthcare decisions. There are multiple barriers to health literacy that include lack of understanding the language being spoken to the patient, decreased communication between patient and healthcare provider, lack of resources for the patient, and lack of understanding the need for healthcare and engaging in risky behaviors. Taking medication as prescribed after asking the nurse questions to clarify information demonstrates health literacy. Health teaching cannot be effective if either or both the patient and nurse cannot communicate effectively in the same language. If the patient is unable to read the prescription labels or understand the need for the medications to continue feeling well, then this can negatively impact decision making regarding healthcare.

Which teaching strategy is typically most effective for presenting information to large groups? a) Distributing printed materials b) Lecturing using audiovisual format c) Online sources of information d) Role modeling

ANS: B Lecturing using audiovisual materials appeals to learners who best process information by hearing and seeing. From a practical point of view, a lecture format (traditional classroom or webinar) is efficient and effective with large groups. Although printed materials can help to reinforce information taught during a lecture, this can be problematic for auditory learners or those whose primary spoken language is not English. Online sources of information are ideal of learners who learn best by doing (kinesthetic learners). Role modeling is most effective for individuals or small groups of learners, especially when the relationship between the instructor and learner is meaningful.

The nurse manager is devising a teaching schedule for the staff who are about to begin using a new type of patient bed in the ICU. Implementation is planned in 6 weeks. When is the best time for the manager to schedule the teaching sessions? a) Immediately b) One week before implementation c) Two weeks before implementation d) Four weeks before implementation

ANS: B People retain information better when they have the opportunity to use it soon after it is presented. Therefore, the nurse manager should schedule teaching sessions 1 week before implementation of the equipment. If classes are scheduled too early, the nurses might forget how to use the equipment before it is implemented. If the teaching is offered immediately prior to use with patients, there wouldn't be an adequate opportunity to practice skills and ask appropriate questions regarding use of the new device.

Before inserting a nasogastric tube, the nurse reassures the client. Reassuring the client requires which type of nursing skill? a) Psychomotor b) Interpersonal c) Cognitive d) Critical thinking

ANS: B Reassuring the client is an interpersonal skill. Inserting the nasogastric tube requires psychomotor skills. Checking catheter placement after insertion requires cognitive and psychomotor skills. Assessing whether there is an indication for the nasogastric tube requires critical thinking skills.

The mother of a child participating in a research study that uses high-dose steroids wishes to withdraw her child from the study. Despite reassurance that adverse reactions to steroids in children are uncommon, the mother still does not change her mind. By withdrawing from the study, the mother is exercising which right? The right a) Not to be harmed b) To self-determination c) To full disclosure d) Of confidentiality

ANS: B The mother is exercising the right to self-determination. This refers to the right of the participant (or parent, in the case of a minor) to withdraw from a research study at any time and for any reason. The right not to be harmed outlines the safety protocols of the study. All research participants also have the right to full disclosure. This guarantees the participants answers to questions, such as the purpose of the research study, the risks and benefits, and what happens if the patient feels worse as a result of the study. Moreover, participants also have the right to confidentiality. Typically that right is preserved by giving participants an identification code rather than associating them by name.

How can the nurse best provide teaching for a patient whose primary spoken language is not the same as hers? a) Provide written materials in the patient's primary language. b) Make arrangements to teach using an interpreter. c) Provide a demonstration and request a return demonstration. d) Use visual teaching aids to convey information.

ANS: B The nurse can best provide teaching for the patient whose primary spoken language is not the same as her own by requesting the aid of an interpreter. An interpreter can help the nurse to communicate clearly and accurately when assessing learning needs; dispersing the information; providing feedback to learners; and determining whether teaching is effective. An interpreter also allows the patient to ask questions when necessary and for the healthcare provider to respond with meaningful information. Written materials in the patient's primary language can help reinforce teaching. Demonstrating and requesting a return demonstration may be difficult if the patient does not understand the spoken language of the nurse. Visual aids may also be helpful for some learners, but they should not be the primary method for teaching, nor do they offer an opportunity for the exchange of information through questions, demonstration, or discussion.

For which patient is the nursing diagnosis Deficient Recall most appropriate? a) Adolescent with Down syndrome and newly diagnosed with cardiac problem b) Young adult admitted with acute renal failure who requires hemodialysis c) Middle-aged woman with breast cancer receiving the last round of chemotherapy d) Older adult with a long-standing history of type 1 diabetes admitted with a foot ulcer

ANS: B The young adult patient admitted with acute renal failure who needs hemodialysis will probably have Deficient Recall related to his treatment regimen. Patients with chronic illness, such as diabetes or cancer, are most likely to be knowledgeable about the disease and course of treatment; therefore, the nursing diagnosis Deficient Recall is less relevant than it is to a patient who is newly diagnosed. The adolescent patient with Down syndrome would have a nursing diagnosis of Impaired Ability to Learn.

The nurse educator in the local hospital is developing a plan to implement research into nursing care practices. What are some of the barriers she may encounter in this implementation process? Select all that apply. a) Not enough nursing research has been published. b) There is a negative attitude toward research. c) There is a lack of support from the employing hospital. d) Most nursing research is not relevant to hospital practice.

ANS: B, C Barriers to using nursing research include a lack of knowledge of nursing research, negative attitudes toward research, inadequate forums for disseminating research, lack of support from the employing institutions, and study findings that are not ready for the clinical environment. There is an abundance of nursing research and evidence-based nursing research providing sound evidence on which to base nursing care. Many times, this is in the form of clinical practice guidelines.

The nurse explains to a patient that dressing changes will improve healing and decrease infection and then demonstrates the correct aseptic technique to the patient. The patient is asked to return a demonstration of this dressing change and to describe the reasons for it to the nurse. This example includes what learning domain(s)? Select all that apply. a) Affective b) Active c) Cognitive d) Psychomotor e) Passive

ANS: B, C, D The item shows cognitive learning; from the nurse's description of the task, the client learns how and why to do the dressing change. Psychomotor learning occurs as the client returns the demonstration of the dressing change. With the client describing the task and demonstrating it, the nurse can evaluate the client's level of understanding and skill as well. Affective learning includes integrating new ideas, considering one's own preferences, and committing to a new idea. The question does not address the patient's attitudes toward the learning experience. Active learning involves the learner's participation. A return demonstration is a classic example of active learning in which the participant experiences the content. Passive learning occurs when the learner is a recipient of information but does not engage in it, ask questions, or demonstrate mastery of the learning.

The nurse reviews a nursing order for a patient who is 4 days post-operative after hip surgery. It reads: Assist patient in bathing each morning. The nurse assesses the patient and notes that the patient is independent in bathing. What should the nurse do next? a) Assist with the bath as ordered b) Delegate the bath to the nursing assistant c) Discontinue the nursing order on the plan of care d) Collaborate with the nurse who originally wrote the order

ANS: C After assessing and evaluating patient progress, the nurse will use her conclusions about goal achievement to decide whether to continue, modify, or discontinue the nursing order on the plan of care. In this item, the nurse has assessed patient independence and therefore can discontinue this nursing order from the plan of care.

Which of the following nursing interventions is an indirect-care intervention? a) Emotional support b) Teaching c) Consulting d) Physical care

ANS: C An indirect-care intervention is an activity performed away from the client on behalf of the client. Indirect-care interventions include consulting with other healthcare team members, making referrals, advocating, and managing the environment. Direct-care interventions include emotional support, patient teaching, and physical care.

An older adult patient who underwent bowel resection is recovering from surgery without complication. He ambulates in the hallway and requires little analgesia for pain. During the healthcare team's morning rounds, the surgeon informs the patient that the lesion removed was cancerous. Which factor will likely be the patient's most significant obstacle for learning? a) The patient's baseline physical condition b) A negative environmental influence c) Anxiety associated with the new diagnosis d) Reduced ability to understand the diagnosis

ANS: C Anxiety associated with the new diagnosis of cancer will most likely be a barrier to learning in this patient. Fear of the unknown, fear of pain, fear of physical discomfort with treatment options, fear of altered role in home or work life, and many other fears accompany the anxiety that patients often experience when potentially life-threatening diagnoses are communicated. The patient has been ambulating and requiring a minimal amount of pain medication; therefore, his physical condition is probably not the most significant barrier to learning. Simply because the patient is an older adult does not suggest he has reduced capacity to learn.

A participant in a research study informs the nurse researcher that he has decided to withdraw from the study citing personal reasons. The most appropriate action by the researcher is to: a) Inform the participant that the signed consent form requires him to remain in the study b) Review the purpose of the study with the participant and encourage him to remain c) Support the participant in his withdrawal from the study d) Discuss with the research team strategies to keep the participant in the study

ANS: C At any time in a study, the participant has the right to stop participating, for any reason. As the nurse or researcher, you are responsible to support a participant during the process of withdrawing from a study. Do not allow anyone to coerce the participant into remaining in the study.

Which statement by the nurse best demonstrates clear communication to nursing assistive personnel (NAP) about delegating a task? a) "Record how the patient's intake and output of fluids, please" b) "Take the patient's temperature, pulse, respirations, and blood pressure every 2 hours today." c) "Take the patient's temperature every 4 hours; notify me if it is greater than 100.5°F (38.1°C)." d) "Assist the patient with all of her meals so she will take in more calories."

ANS: C Clear communication about a task (such as "Take the patient's temperature . . . ") tells the NAP exactly what the task is, the specific time at which it needs to be done, and the method for reporting the results to the registered nurse. The other options are vague and leave room for misinterpretation.

Which theorist developed the nursing theory known as the Science of Human Caring? a) Florence Nightingale b) Patricia Benner c) Jean Watson d) Nola Pender

ANS: C Dr. Jean Watson developed the nursing theory known as the Science of Human Caring. Her theory describes caring from a nursing perspective. Florence Nightingale developed the theory that stated that a clean environment would improve the health of patients. By changing the care environment, she dramatically reduced the death rate of soldiers. Dr. Patricia Benner's theory described the progression of a beginning nurse who learns to be an expert nurse. Nola Pender's theory on health promotion became the basis for most health promotion teaching done by nurses.

The certified nursing assistant (CNA) is feeding a patient and notes that the patient is having difficulty swallowing. She reports this to the primary registered nurse. What should the nurse do first? a) Assign the task to a more experienced CNA b) Feed the patient herself c) Assess the patient and place on NPO status d) Call the primary care provider

ANS: C Feeding a patient is a delegatable task that a CNA can perform. However, once it is reported to the registered nurse that the patient is having difficulty swallowing, this becomes a safety issue that the registered nurse must address. This circumstance is then no longer delegatable for any CNA regardless of experience. The first action by the nurse is to assess the patient and place the patient on NPO status until a primary provider is notified for further orders.

Which phrase is stated as a teaching goal (as compared with an objective) for a patient who had bowel resection with creation of a colostomy? The patient a) Empties the colostomy appliance when half filled b) Performs skin care around the stoma site c) Will perform ostomy self-care within 3 days after surgery d) Applies a new ostomy appliance, making sure it adheres properly

ANS: C Performing ostomy self-care is an appropriate goal for a patient who needs to learn colostomy self-care after surgery. Emptying the colostomy appliance demonstrates a behavioral learning objective, not a broad teaching goal. Performing skin care is also a desired skill stated by a learning objective. Applying an ostomy device is another observable learning objective.

It is a busy day on the medical-surgical floor, and the nurse must teach a patient ready for discharge about his medications. How can the nurse most efficiently use her time and provide this education? a) Write down instructions so the patient can read them at home. b) Discuss the information while assisting the patient with his bath. c) Educate the patient about his medications as each one is given. d) Follow up with the patient after discharge with a phone call.

ANS: C Teaching does not have to be performed in a formal session but is often most effective at a teachable moment when the information is perceived as most relevant, such as at the time the medication is given to the patient. Additionally, the information is more memorable when the patient can see the actual dose and identify it with the information presented. A teaching session about wound care would be appropriate during bathing but not medication teaching. Providing the patient written instructions without discussing the information does not allow the patient an opportunity to ask questions or the nurse to verify that the patient understands the instruction. The patient should not be discharged without education about his prescribed medications, including what it is for, how to take the it, instructions regarding dosing, what side effects can occur, and when to stop taking the medication.

Which technique is best for teaching a nursing assistant how to perform finger-stick glucose testing? a) Provide a manufacturer's pamphlet with detailed instruction. b) Explain the best technique for performing glucose testing. c) Demonstrate the procedure; then ask for a return demonstration. d) Suggest that the assistant watch a DVD showing the procedure.

ANS: C The best way to teach a psychomotor skill is to demonstrate the procedure and then ask for a return demonstration. Supplementary written information or DVD can also be supplied to the patient to reinforce learning. However, they are not the best method for teaching a psychomotor skill; enacting the procedure is more effective.

Who is the primary decision maker when caring for healthy adult clients? a) Provider b) Family c) Client d) Nurse

ANS: C The client is the primary decision maker in the care of healthy clients. The nurse functions as a teacher and health counselor. The provider plays a role in health promotion and screening. The family may give input, but the client is the decision maker.

The nurse is performing preoperative teaching for a client who is scheduled for surgery in the morning. The client does not at present have any respiratory problems. The nurse's teaching plan includes coughing and deep-breathing exercises. Which type of nursing intervention is the nurse performing? a) Health promotion b) Treatment c) Prevention d) Assessment

ANS: C The nurse is teaching the client coughing and deep-breathing exercises, which help prevent postoperative pneumonia. Therefore, the nurse is employing a prevention intervention. Prevention interventions are used to help prevent complications, such as postoperative pneumonia. Health promotion interventions promote a client's efforts to achieve a higher level of wellness. Treatment interventions treat disorders, relieve symptoms, and carry out medical orders. Assessment interventions detect changes in the client's condition and detect potential problems.

The nurse and other hospital personnel strive to keep the patient care area clean. This most directly illustrates the ideas of which nursing theorist? a) Virginia Henderson b) Imogene Rigdon c) Katherine Kolcaba d) Florence Nightingale

ANS: D Florence Nightingale was instrumental in identifying the importance of a clean patient care environment. During the Crimean War, Nightingale dramatically reduced the death rate of soldiers by changing the healthcare environment. Virginia Henderson identified 14 basic needs that are addressed by nursing care. Imogene Rigdon developed a theory about bereavement in older women after noticing that older women handle grief differently than do men and younger women. Katherine Kolcaba developed a theory of holistic comfort in nursing.

A psychiatrist prescribes oral aripiprazole 10 mg daily for a client with schizophrenia. This medication is unfamiliar to the nurse, and she cannot find it in the hospital formulary or other references. How should she proceed? a) Administer the medication as ordered. b) Hold the medication and notify the prescriber. c) Consult with a pharmacist before administering it. d) Ask the patient's RN for information about the medication.

ANS: C The nurse must recognize when she does not have the knowledge or skill needed to implement an order. Because the nurse is unfamiliar with the medication, that does not mean she should hold it and delay patient treatment. It is wisest to first consult with the pharmacist for information before administering the medication to ensure safe practice. Administering the medication as ordered, without knowing its expected actions and side effects, at the least prevents adequate reassessment; at the most, it is dangerous. Holding the medication and notifying the prescriber prevents the client from receiving timely treatment—many drugs are less effective if a consistent schedule is not maintained. Asking another nurse to administer the medication is also unsafe because it cannot be assumed that the other nurse has the correct knowledge. In addition, the nurse caring for the client must assess for adverse reactions to the medication.

Assume all of the following written instructions about digoxin provide correct information for patient care. Which one is best worded for patient understanding? a) Obtain your radial pulse every morning before taking your digoxin dose. b) Return to your healthcare provider for monthly laboratory studies of your digoxin levels. c) Call your provider if you notice that objects look yellow or green. d) Always take the same brand of medication because certain brands may not be interchangeable.

ANS: C The nurse should provide written instructions that contain short sentences and easy-to-read words. If instructions are written at too high a reading level, the patient may not understand and make a harmful error in dosing. Calling the provider when objects look yellow or green is the clearest statement for patient teaching because the instruction is short, concrete, and written with easy-to-understand words. Patient instructions must not contain words that require a higher level of reading or medical jargon. The instruction pertaining to being consistent with brand use is too wordy, especially for patients who are ill or for whom English is not a primary language.

The new nursing student is working on a surgical unit and observes some patients developing a low-grade fever of 99°F a few hours after their surgery. The most appropriate action for the student to take to gain some insight into her observation is to: a) Ask an experienced nursing instructor why this might be occurring b) Talk to someone about starting a research study c) Formulate a searchable question and research the literature d) Speak with a surgeon from the unit

ANS: C When you have found a topic of interest, the first step is to state it in the form of question to help narrow a search. A question stated too broadly may yield overwhelming and irrelevant results. A question stated too narrowly may yield no results. Once the question is formed the next step is to look for research articles related to your inquiry. Asking an instructor or surgeon for an answer may yield an immediate and narrow response. Talking to someone about starting a research study is most likely beyond the level of a new nursing student.

A mother tells the nurse she is worried that her 20-year-old daughter lacks the understanding regarding the need for follow-up care after her discharge. Which of the following behaviors suggests that the patient needs further discharge teaching? Select all that apply. The patient: a) States she will be on time for her scheduled appointment b) Asks the nurse many questions about her discharge care c) States she does not understand much English d) Watches television while the nurse is speaking to her e) Plans to get medications from the pharmacy on her way home

ANS: C, D Poor language fluency and comprehension interfere with learning. The client watching television while the nurse is giving discharge instructions shows a lack of readiness for learning.

Which of the following is the best example of a well-written nursing order? a) Provide emotional support to patient and family as needed. b) Bathe patient every day. c) Follow fluid restriction of 1,500 mL per day. d) Insert Foley catheter if patient has not voided within 8 hours.

ANS: D A well-written nursing order includes: Date, subject, action verb, time and limits, and a signature. The best example is the nursing order to insert a Foley catheter if the patient has not voided in 8 hours. This example provides the most information and direction for the nurse, as it contains the subject, action verb, time frame, and limits. The remaining options do not provide enough direction and information for the nurse, as they are vague and nonspecific

During advanced cardiac life support (ACLS) training, a nurse performs defibrillation using a mannequin. Which teaching strategy is being employed? a) One-to-one instruction b) Computer-assisted instruction c) Role modeling d) Simulation

ANS: D ACLS training uses simulation by creating a scenario using resuscitation mannequins and teaching healthcare workers to respond appropriately to life-threatening cardiopulmonary events. The nurse is demonstrating the skill of defibrillation. ACLS certification requires learners to perform the skill for the examiner. With one-to-one instruction, one instructor orally presents information to one student. With ACLS training, the healthcare team is involved and not just individual nurses. In role modeling, the teacher teaches by example, demonstrating the behaviors (not skills) that need to be acquired by learners.

The nurse is caring for a client who was newly diagnosed with type 2 diabetes mellitus. Which intervention by the nurse best promotes client cooperation with the treatment plan? a) Teaching the client that he must lose weight to control his blood sugar b) Informing the client that he must exercise at least three times per week c) Explaining to the client that he must come to the diabetic clinic weekly d) Determining the client's main concerns about his diabetes

ANS: D Determining the client's main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoring equipment, he may disregard any teaching about the procedure. Although it is often important for a diabetic client to exercise and lose weight to control blood sugar levels, the client must want to do both. He will not exercise or lose weight simply because he is told to do so. The nurse must assess the client's support systems and resources, not merely tell him he must come to the diabetic clinic weekly. Some clients do not have access to transportation and, therefore, could not come to the clinic without social service intervention. Remember that knowledge does not necessarily change behavior.

Which of the following is the best example of the implementation phase of the nursing process? a) Patient verbalizes pain is reduced from an 8 to a 3 after receiving pain medication. b) Nurse observes that patient has a small, quarter-sized skin tear over coccyx area. c) Nurse writes in the care plan: Patient requires 2 person assist with ambulation to bathroom. d) Nurse inserts Foley catheter after reporting to physician patient's inability to void.

ANS: D Implementation is the action phase of the nursing process. It involves thinking but the emphasis is on doing. During implementation, the nurse will perform or delegate planned interventions. In short, implementation is doing, delegating, and documenting. A patient verbalizing that pain is reduced after receiving pain medication is part of the evaluation phase. Observing or noticing a skin tear relates to assessment and evaluation of skin condition. Writing on the care plan of a patient requiring assistance to the bathroom is an example of assessment and planning.

A patient who emigrated from India is admitted to the medical step-down unit with a bowel obstruction. A nasogastric (NG) tube is inserted to decompress her stomach. She asks the nurse whether her daughter can bring in garlic to administer through her NG tube. The nurse tells the patient that she will ask the physician when she makes rounds. This nurse is using the theory developed by which nurse theorist? a) Betty Neuman b) Dorothea Orem c) Callista Roy d) Madeline Leininger

ANS: D The nurse is using the theory developed by Madeline Leininger. Leininger's theory focuses on the values of cultural diversity. According to her theory, the nurse must make cultural accommodations for the health benefit of the patient.

When should the nurse collect evaluation data for this expected outcome? "Patient will maintain urine output of at least 30 mL/hour." a) At the end of the shift b) Every 24 hours c) Every 4 hours d) Every hour

ANS: D The nurse should collect evaluation data as defined in the expected outcome. For instance, in this case, the nurse would check the patient's urine output every hour because the goal statement specifies an hourly rate (30 mL/hour). The unit of measurement in the goal guides how often the nurse would reassess the patient.

When the nurse is giving instructions for discharge, he notices that the television is on and he is eating a meal. The best thing for the nurse to do to ensure that the patient's discharge teaching is understood is to: a) Review all important discharge teaching while in the room b) Ask whether the patient has any questions about the discharge c) Inform the patient that the instructions are on the discharge sheet d) Arrange another time with the patient to review the discharge teaching

ANS: D The nurse understands that multiple distractions in the client's room, including having the television on and eating a meal, can be barriers to learning. The nurse must assess each situation to identify the best time to effectively teach the client. Therefore, the nurse identifies that there are too many distractions at that time and speaks to the client to determine a mutually agreeable time for the discharge teaching to be done. Attempting to review previous teaching will be less effective with the many distractions occurring in this scenario. Trying to discuss the discharge teaching in front of the client's family and friends may be revealing information the client prefers to keep private. Providing a client a written set of instructions does not guarantee understanding of the information and it is imperative for the nurse to review all of this information with the client before discharge.

The nurse preparing a teaching plan ensures that the information is tailored to the client's life experiences and learning level. These are examples of which right of teaching? a) Time b) Context c) Content d) Method

ANS: D The right content needs to be aligned with the client's needs, learning level, and life experiences. The right time is when the learner is free of pain, anxiety, and stress, which can affect the ability to learn. The nurse must have insufficient time to do the teaching. The right context includes a calm environment free from distractions, and one that is private with a soothing atmosphere. The right method assesses whether teaching strategies are varied, and fit the client's learning ability and style.

A nurse makes a nursing diagnosis of Acute Pain related to the postoperative abdominal incision. She writes a nursing order to reposition the client in a comfortable position using pillows to splint or support the painful areas. What type of nursing intervention did the nurse write? a) Collaborative b) Interdependent c) Dependent d) Independent

ANS: D Writing an order to reposition the client in a comfortable position is an example of an independent nursing intervention, one that does not require a physician's order. The nurse is licensed to prescribe, perform, or delegate the intervention based on her knowledge and skills. A collaborative or interdependent intervention is one that is carried out in collaboration with other health team members, such as providing the client with a sodium-restricted diet. A dependent intervention is prescribed by a physician or advanced practice nurse, for example, "Administer oxygen at 2 L/min via nasal cannula."