Ch19- EAQ
Which level of prevention describes the nurse working in collaboration with a physiotherapist to help aid the ambulatory functions of a patient who suffered a motor vehicle accident? 1 Primary 2 Secondary 3 Tertiary 4 Quaternary
3
Which prevention level would describe a clinic nurse screening a patient for diabetes? 1 Primary 2 Secondary 3 Tertiary 4 Quaternary
2
Which element is a chief component of the nursing process? Select all that apply. One, some, or all responses may be correct. 1 Diagnosis 2 Detection 3 Assessment 4 Identification 5 Implementation
1,3,5
Which activity would the nurse perform when implementing indirect care measures? 1 Positioning the patient correctly 2 Collecting and transporting labeled specimens 3 Administering vaccines 4 Teaching the patient about home care
2
Which implementation skill describes a nurse explaining to the patient about inserting a feeding tube? 1 Cognitive 2 Technical 3 Interpersonal 4 Psychomotor
3
Which sequence would the nurse follow for making decisions about implementing interventions? 1. Judge the value of the consequences to the patient. 2. Determine the probability of possible consequences. 3. Review all possible consequences associated with each intervention. 4. Review all possible interventions for the patient.
4,3,2,1
Which action would the nurse take when administering a new, unfamiliar medication to a patient who cannot have food or fluids for 24 hours? Select all that apply. One, some, or all responses may be correct. 1 Ask the pharmacist for help. 2 Consult an experienced nurse for help regarding the drug. 3 Administer a different but similar drug. 4 Look up the medication in a drug book. 5 Request that the health care provider prescribe an oral medication.
1,2,4
Which factor would the nurse consider when making discharge plans for activities of daily living (ADLs)? Select all that apply. One, some, or all responses may be correct. 1 A paralyzed patient will need permanent assistance for ADLs. 2 Patients should be encouraged to participate in ADLs. 3 A patient with a fractured arm will need assistance writing checks. 4 Family members can be allowed to assist the patient, as needed. 5 Only a professional nurse can provide ADLs.
1,2,4
Which action would the nurse perform when managing supplies required for a patient's minor procedure? 1 Keep some extra supplies handy. 2 Ensure that the supplies are outdated. 3 Unseal all the supplies for easy access. 4 Place the supplies away from the area of the procedure.
1
Which activity would the nurse include in a nursing plan for indirect care of a patient? 1 Manage the patient's environment. 2 Administer medication on time. 3 Change the intravenous solution when empty. 4 Counsel the patient about coping strategies.
1
Which implementation skill describes the nurse considering facts about nausea, the anatomy of the gastrointestinal tract, and the physical mechanisms for nausea and vomiting? 1 Cognitive 2 Interpersonal 3 Psychomotor 4 Consultative
1
Which level of prevention describes a nurse administering a vaccine to an infant? 1 Primary 2 Secondary 3 Tertiary 4 Rehabilitation
1
Which level of prevention describes a nurse conducting health awareness training programs at a community center? 1 Primary 2 Secondary 3 Tertiary 4 Indirect
1
Which action would the nurse take when the patient who is nothing by mouth (NPO) (no food or fluids allowed) develops an adverse reaction to a new intravenous (IV) drug? Select all that apply. One, some, or all responses may be correct. 1 Record the reaction. 2 Stop further administration of the drug. 3 Notify the health care provider. 4 Start oral medication. 5 Stop the medication and administer it again after the reaction subsides.
1,2,3
Which principle of care coordination would the nurse use to achieve a desired outcome for patients? Select all that apply. One, some, or all responses may be correct. 1 Organizational skills 2 Good time management 3 Appropriate use of resources 4 Providing the single best intervention 5 Avoiding prioritization of patient needs
1,2,3
Which action would the nurse perform when revising a nursing care plan? Select all that apply. One, some, or all responses may be correct. 1 Revise the nursing diagnoses. 2 Add new data with appropriate dates. 3 Maintain irrelevant nursing diagnoses. 4 Choose the method of evaluation for monitoring patient outcomes. 5 Continue the old, specific interventions for new nursing diagnoses.
1,2,4
Which information accurately describes a physical care technique? Select all that apply. One, some, or all responses may be correct. 1 Staying organized while caring for the patient 2 Protecting oneself and the patient from injury 3 Ensuring that the patient has medical reports 4 Using proper hygienic infection control practices 5 Preparing a discharge summary and rehabilitation plan
1,2,4
Which intervention would be appropriate for a postoperative patient who is on bed rest and at risk of skin injuries after surgery? Select all that apply. One, some, or all responses may be correct. 1 Reposition the patient frequently. 2 Administer analgesics before turning. 3 Teach the patient about postoperative care. 4 Use pressure relief devices, if necessary. 5 Ambulate the patient.
1,2,4
Which nursing intervention is an example of direct care for a patient? Select all that apply. One, some, or all responses may be correct. 1 Administering medications 2 Inserting an intravenous (IV) line 3 Keeping the patient's room infection free 4 Counseling the patient about required care 5 Keeping all of the patient's paperwork updated
1,2,4
Which action would a student nurse take when asked to perform a procedure that the student nurse has been trained in but has not performed in the hospital? Select all that apply. One, some, or all responses may be correct. 1 Check the hospital's procedure manual to obtain more information. 2 Request the unit manager assign the procedure to another student nurse. 3 Ask an experienced nurse for supervision and guidance during the procedure. 4 Verbalize the steps of the procedure with an instructor before performing it. 5 Refuse to perform the procedure.
1,3,4
Which activity would the nurse perform when preparing for the implementation phase of the nursing process? Select all that apply. One, some, or all responses may be correct. 1 Reassessing the patient 2 Focusing on preventive measures 3 Organizing resources and care delivery 4 Counseling and motivating the patient 5 Reviewing and revising the existing nursing care plan
1,3,5
Which activity is classified as an instrumental activity of daily living (IADL)? Select all that apply. One, some, or all responses may be correct. 1 Shopping 2 Getting magnetic resonance imaging (MRI) 3 Ambulating 4 House cleaning 5 Preparing meals
1,4,5
Which component is an element of the American Nurses Association (ANA) standards of practice and scope of nursing practice? Select all that apply. One, some, or all responses may be correct. 1 Describes what a nurse is licensed to perform 2 Is a definition of skills competencies for nurses 3 Sets standards for diagnosing diseases and disorders 4 Identifies the nature and intent of the ways nurses intervene for patients 5 Is an authoritative statement regarding the duties all nurses are expected to perform
1,4,5
A home-health nurse provides palliative care for a patient in a community setting. The patient states, "The pain pills that I have been taking are not as effective as they used to be." After reviewing the patient's standing orders, which action does the nurse take? 1 Arranges for a hospital transfer 2 Increases the medication dosage 3 Schedules an office appointment 4 Contacts the health care provider for a new order
2
The nurse reviews potential interventions for a patient who is experiencing pain. When considering the administration of an analgesic, the nurse identifies that the medication may cause an adverse reaction, including increasing the patient's fall risk. The nurse is demonstrating which principle of critical judgment and decision-making? 1 Review the set of all possible nursing interventions for the patient's problem. 2 Review all possible consequences associated with each possible nursing action. 3 Judge the value of the consequences to the patient. 4 Determine the probability of all possible consequences.
2
Which action would the nurse take when the patient asks for a bedpan as the nurse is reassessing the patient? 1 Call the assistive personnel (AP) and ask him or her to bring a bedpan for the patient. 2 Assist the patient onto the bedpan. 3 Quickly finish the reassessment. 4 Reassure the patient that an AP will bring a bedpan soon.
2
Which action would the nurse take when unable to perform a complex intervention successfully? 1 Continue until the intervention is successfully completed. 2 Ask for assistance from an experienced nurse. 3 Tell the patient about the inability to perform it. 4 Compromise on the intervention to make it easier to perform.
2
Which direct care measure would the nurse be using when consulting with the dietitian and health care provider to determine the initial rate that will be prescribed for the tube feeding to lessen the chance of diarrhea? 1 Preventive 2 Controlling for an adverse reaction 3 Consulting 4 Counseling for nutritional needs
2
Which priority action would the nurse take before administering a new drug? 1 Confer with a colleague before giving the medication. 2 Consult with a pharmacist to obtain knowledge about the medication. 3 Ask the patient about the medication. 4 Administer the medication as prescribed and on time.
2
Which information about standing orders is accurate? Select all that apply. One, some, or all responses may be correct. 1 They provide instructions from the unit manager about care in emergencies. 2 They are preprinted documents that contain orders for various clinical problems. 3 They provide legal protection to the nurse when caring for the patient. 4 They are signed by the licensed prescribing health care provider in charge at the time of implementation. 5 They are signed by the patient or the patient's relative before the treatment is started.
2,3,4
When does implementation begin? 1 During the assessment phase 2 Immediately in some critical situations 3 After the care plan has been developed 4 After mutual goal setting between the nurse and patient
3
Which action does the nurse take right before implementing interventions? 1 Review the care plan. 2 Decide if the outcomes remain appropriate. 3 Reassess the patient. 4 Compare assessment findings to validate existing nursing diagnoses.
3
Which action indicates that the nurse is using physical care techniques? 1 Meeting the patient's expressed needs 2 Performing indirect care measure 3 Using safe patient-handling procedures 4 Providing a hand-off report
3
Which method would the nurse use when teaching a patient about foot care? 1 Give instructions once in a loud voice. 2 Provide instructions, asking the patient to repeat the instructions at the end. 3 Repeat instructions as needed, having the patient do a return demonstration. 4 Present instructions to the family, having the family explain instructions to the patient.
3
Which response would the nurse make for a patient who expresses confusion about how to manage a leg wound after discharge? 1 Provide a written document that contains the necessary instructions. 2 Tell the patient that a relative will be taught how to take care of the wound. 3 Explain and demonstrate the necessary action to the patient. 4 Inform the patient that it will be explained later during discharge.
3
Which action would the nurse take when, right before starting the intravenous (IV) line, the patient needs to void (urinate)? 1 Sedate the patient. 2 Start the IV line immediately. 3 Insert a Foley catheter. 4 Assist the patient to the bathroom.
4
Which type of implementation skill is described when the nurse correctly administers an enema solution to a patient? 1 Interpersonal 2 Cognitive 3 Collaborative 4 Psychomotor
4
Which type of order describes a prewritten prescription in the intensive care unit (ICU) that states in case of a headache, acetaminophen is to be given to the patient? 1 Protocol 2 Intervention 3 Standard prescription 4 Standing order
4
