Ch. 6 NCLEX Questions Foundations of Nursing

A patient who is 14 hours post-op complains of SOA. Which action should be implemented first? 1. Auscultate the lungs 2. Question about previous SOA 3. Check for an order for O2 therapy 4. Reassure the patient

1. Auscultate the lungs Rationale: The patient should be reassured to prevent an increase in anxiety that could make the shortness of breath worse. Then the lungs would be auscultated and the medical record checked for an order for oxygen if breath sounds indicate the need.

A difference in the in the assessment of the patient entering a long-term care facility versus that of a hospital patient is that the long-term care resident is assessed for: 1. Functional abilities 2. Psychosocial concerns 3. Emotional problems 4. Skin problems

1. Functional abilities Rationale: Functional abilities are assessed to determine how much assistance with activities of daily living the resident will need while in the facility.

You assist a patient with her bath, change her dressing, rub her back, give her medication, review her dietary needs, and assist with physical therapy exercises. Which are examples of interdependent nursing actions? (SATA) 1. Reinforcing dietary education 2. Changing her dressing 3. Assisting with her exercises 4. Giving her a back rub 5. Administering medication

1. Reinforcing dietary education 3. Assisting with exercises Rationale: (1) Diet is prescribed by the primary care provider and the dietary patient education is done by the dietitian. The nurse reinforcing that patient education is an interdependent action. (2) Exercises are prescribed by the primary care provider and taught by the physical therapist. The nurse assisting the patient to do the exercises is an interdependent action. Dressing changes and medication administration are dependent actions; backrub and bath are considered independent nursing actions.

An example of a dependent nursing action would be: 1. Starting the continuous passive motion (CPM) machine 2. Providing a back massage 3. Encouraging the consumption of more fluid 4. Changing the patient's linens after an episode of incontinence

1. Starting the continuous passive motion (CPM) machine Rationale: The use of a CPM machine always requires an order, and starting the machine is a dependent action; a back massage, encouraging fluids, and changing linens when soiled do not require an order.

Before carrying out a dependent nursing action, the nurse: (SATA) 1. Makes certain the family is in agreement with the order 2. Verifies that the PCP's order is in the medical record 3. Considers whether there is any contraindications for the action 4. Reviews agency policies and procedures manual as needed 5. Gathers all equipment and supplies needed for the action

2. Verifies that the PCP's order is in the medical record 3. Considers whether there is any contraindications for the action 4. Reviews agency policies and procedures manual as needed 5. Gathers all equipment and supplies needed for the action Rationale: Before carrying out a dependent nursing action, the nurse verifies the order, considers whether there is any contraindication to carrying out the order, ensures to follow the agency policy, and gathers all supplies needed to carry out the order.

The nurse evaluates the care provided to the patient by determining: 1. Whether she is beginning to improve 2. Whether all planned interventions were carried out 3. Whether expected outcomes have been achieved 4. Whether she is well enough for discharge

3. Whether expected outcomes have been achieved Rationale: Evaluation is performed by considering if the interventions have achieved the expected outcomes.

When evaluating a patient admitted with a lower respiratory tract infection, which data are most important for the nurse to obtain? 1. Level of pain or discomfort 2. Medications taken at home 3. Duration of the illness 4. Bilateral lung sounds

4. Bilateral lung sounds Rationale: Auscultating the lung sounds to obtain data about the quality of air movement is the most important action for this patient with a respiratory infection.