NR 226 Exam 1 - Review Questions

Unmet and partially met goals require the nurse to do which of the following? (Select all that apply.) A. Redefine priorities B. Continue intervention C. Discontinue care plan D. Gather assessment data on a different nursing diagnosis E. Compare the patient's response with that of another patient

A & B -When you determine that a goal has not been met or has been met only partially, intervention must continue; and the fact that the health problem still exists suggests that priorities may need to be redefined. You do not discontinue a plan unless a goal has been achieved. Evaluation never involves comparing a patient's data with that of another patient. A patient may develop new diagnoses at any time, but assessment of a new diagnosis does not address goals for an existing diagnosis.

.A nurse who is working on a surgical unit is caring for four different patients. Patient A will be discharged home and is in need of instruction about wound care. Patients B and C have returned from the operating room within an hour of each other, and both require vital signs and monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical therapy. Which of the following activities by the nurse represent(s) use of clinical decision making for groups of patients? (Select all that apply.) A. Consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction. B. Think about past experience with patients who develop postoperative complications. C. Decide which activities can be combined for patients B and C. D. Carefully gather any assessment information and identify patient problems.

A & C -Considering how to involve patients in decisions and how to combine nursing activities to be more organized and allow for resolving more than one problem at a time are examples of clinical decision making for groups of patients. Thinking about past experience with patients is an example of reflection, an approach to strengthen critical thinking skills. Gathering assessment information is part of the process of diagnostic reasoning, which should be applied to each patient.

A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply.) A. A problem-focused approach B. A structured comprehensive approach C. Using multiple visits to gather a complete database D. Focusing on the functional health pattern of role-relationship

A & C -The nurse should use a focused approach initially to determine the patient's respiratory status. However, to gather an admission assessment, multiple visits are needed because of the patient's age and level of physical distress. A structured comprehensive approach is not appropriate for this acute situation. Eventually the nurse will want to assess the patient's role-relationship health pattern because of his wife's death. But it is not appropriate at this time.

A nurse identifies several interventions to resolve the patient's nursing diagnosis of impaired skin integrity. Which of the following are written in error? (Select all that apply.) A. Turn the patient regularly from side to back to side. B. Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence. C. Apply a pressure-relief device to bed. D. Apply transparent dressing to sacral pressure ulcer.

A & C -The statements "Turn the patient regularly from side to back to side" and "Apply a pressure-relief device to bed" do not provide specific guidelines for the frequency or type of intervention. The other two options identify specific intervention methods.

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) A. Anxiety related to fear of dying B. Fatigue related to chronic emphysema C. Need for mouth care related to inflamed mucosa D. Risk for infection

A & D -The diagnosis "Anxiety related to fear of dying" is stated correctly, with the related factor being the patient's response to a health problem. Risk for infection is a risk factor for an at-risk diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventive measures. Fatigue related to chronic emphysema is incorrect since chronic emphysema is a medical diagnosis. Need for mouth care related to inflamed mucosa is not a NANDA-I-approved nursing diagnosis.

Which of the following are examples of data validation? (Select all that apply.) A. The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record. B. The nurse asks the patient if he is having pain and then asks the patient to rate the severity. C. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content. D. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement. E. The nurse asks the patient to describe a symptom by saying, "Go on."

A & D -Validation involves comparing data with another source. By asking the patient about pain and then having it rated the nurse collects two assessment findings. The nurse asking an open-ended question about the patient's understanding of the booklet is not data validation. Telling the patient to "go on" is back channeling.

Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply.) A. Acute pain related to lumbar disk repair B. Sleep deprivation related to difficulty falling asleep C. Constipation related to inadequate intake of liquids D. Potential nausea related to nasogastric tube insertion

A, B & D -Acute pain related to lumbar disk repair uses a medical diagnosis as a related factor. Sleep deprivation related to difficulty falling asleep uses a clinical sign rather than a treatable etiology such as "excess noise in environment." Potential nausea related to nasogastric tube insertion uses a diagnostic study as the etiology. None of the etiologies can be managed or treated by nursing intervention.

What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply.) A. Active listening B. Back channeling C. Validating D. Use of open-ended questions E. Use of closed-ended questions

A, B, & D -Active listening allows the patient to speak and shows the nurse's respect for what he or she has to say. Back channeling reinforces interest in what the patient has to say and shows the nurse's desire to hear the full story. Using open-ended questions encourages the patient to tell his or her story and actively describe his or her health status. Validation simply confirms accuracy of data collected. Closed-ended questions do not encourage storytelling.

Which of the following strategies focus on improving nurse-physician collaborative practice? (Select all that apply.) A. Inviting the physician to attend the practice council meeting B. Participating in physician morning rounds C. Placing physician photos and names in unit newsletter D. Contacting physician promptly to discuss patient problems E. Providing a list of physician contact numbers to all staff nurses

A, B, & D -Inviting the physician to attend the practice council meeting, participating in physician morning rounds, and contacting the physician promptly to discuss patient problems improve nurse-physician collaboration by focusing on strategies that are related to professional practice. Collaboration is a process whereby different perspectives are synthesized to better understand complex problems and an outcome that is a shared solution that could not have been accomplished by a single person or organization. Placing physician photos and names in a newsletter and providing physician contact numbers to all staff nurses provide information to the nursing staff and help them identify and contact providers but are not focused specifically on nurses working with physicians to provide patient care.

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply.) A. Goal within reach of the patient B. The nurse's own competency in teaching about insulin C. The patient's cognitive function D. Availability of family members to assist

A, C & D -A goal must be realistic and one that the patient has cognitive and sociocultural potential to reach. The nurse's competency does not influence the patient's goal. However, it may mean that the nurse must consult with a diabetes educator or a more qualified nurse before beginning instruction.

Which of the following statements correctly describe the evaluation process? (Select all that apply.) A. Evaluation is an ongoing process. B. Evaluation usually reveals obvious changes in patients. C. Evaluation involves making clinical decisions. D. Evaluation requires the use of assessment skills.

A, C & D -Evaluation often reveals changes that are not obvious. Changes are often subtle and occur over a period of time.

Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure? (Select all that apply.) A. Seeks necessary knowledge B. Reassesses the patient's condition C. Collects all necessary equipment D. Delegates the procedure to a more experienced staff member E. Considers all possible consequences of the procedure

A, C, & E -You require additional knowledge and skills in situations in which you are less experienced. When you are asked to administer a new procedure with which you are unfamiliar, follow the three choices: seek necessary knowledge, collect necessary equipment, and consider all possible consequences of the procedure. Collecting necessary equipment and considering potential consequences is needed for any procedure.

A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply.) A. The skin around the wound is tender to touch. B. Fluid intake for 8 hours is 800 mL. C. Patient has a heart rate of 78 and regular. D. Patient has drainage from surgical wound. E. Body temperature is 101° F (38.3° C). F. Patient asks, "I'm worried that I won't return to work when I planned."

A, D, & E -These form a pattern of a problem with wound healing. Fluid intake of 800 mL in 8 hours and having a heart rate of 78 are normal findings. The patient indicating some worry about not returning to work when planned may suggest a problem, but more cues are needed to see a pattern that would allow the nurse to clearly identify the problem.

During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient's home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "This hurts too much. I don't see why I have to do this so many times." The nurse applies the critical thinking attitude of integrity in which of the following actions? A. "I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax." B. "I see that you're uncomfortable. I'll call your doctor to decide the next step." C. "Show me exactly where your pain is and rate it for me on a scale of 0 to 10." D. "Is anything else bothering you? Other than the pain, is there any other reason you might not want to do the exercises?"

A. "I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax." -The nurse reviews the position of requiring exercises to restore function and decides to try a different approach to proceed, which is an example of integrity. In calling the doctor for the next step, the nurse does not reinforce the importance of exercises, which is likely the standard of care for this type of patient. In asking the location and strength of the pain the nurse is interpreting further to determine if any other physical problems are developing. In attempting to learn if any other underlying problems exist, the nurse is showing curiosity.

Before consulting with a physician about a patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? A. Cognitive B. Interpersonal C. Psychomotor D. Consultative

A. Cognitive -Thinking and anticipating how to approach implementation involve a cognitive implementation skill. The nurse considers the rationale for an intervention and evidence in nursing science that supports that intervention or alternatives.

The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of: A. Diagnostic reasoning. B. Competency. C. Inference. D. Problem solving.

A. Diagnostic reasoning -In this example the nurse collects information about the patient, sees patterns in the data collected, and makes a nursing diagnosis. This is an example of the diagnostic process.

When a nurse assesses a patient for pain and offers a plan to manage the pain, which principal is used to encourage the nurse to monitor the patient's response to the pain? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy

A. Fidelity -Requiring a return to the patient to evaluate the effectiveness of an intervention exemplifies keeping a promise, a concrete example of fidelity.

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned. Which of the following does the nurse perform first? A. Reconnect the drainage tubing B. Inspect the condition of the IV dressing C. Improve the patient's comfort and turn onto her side D. Obtain the next IV fluid bag from the medication room

A. Reconnect the drainage tubing -The priority is to reconnect the drainage tube. This can be done quickly and prevents fluid loss and reduces risk of infection spreading up into the tube. Next the nurse turns the patient for comfort. With 100 mL of fluid remaining, the nurse has time to perform these tasks. The nurse can inspect the IV dressing last, after going to obtain the next IV fluid bag.

The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? A. Risk for aspiration B. Acute confusion C. Readiness for enhanced coping D. Sedentary lifestyle

A. Risk for aspiration -A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.

Successful ethical discussion depends on people who have a clear sense of personal values. When a group of people share many of the same values, it may be possible to refer for guidance to philosophical principals of utilitarianism. This philosophy proposes which of the following? A. The value of something is determined by its usefulness to society. B. People's values are determined by religious leaders. C. The decision to perform a liver transplant depends on a measure of the moral life that the patient has led so far. D. The best way to determine the solution to an ethical dilemma is to refer the case to the attending physician or health care provider.

A. The value of something is determined by its usefulness to society -Utilitarianism specifically refers to the greatest good for the greatest number of people, whereas goodness is determined primarily by usefulness. The concept is easier to apply in a community where shared values allow for agreement about a definition of usefulness.

Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following describes the role of the nurse in the resolution of ethical dilemmas? A. To articulate his or her unique point of view, including knowledge based on clinical and psychosocial observations B. To await new clinical orders from the physician C. To limit discussions about ethical principals D. To allow the patient and the physician to resolve the dilemma without regard to personally held values or opinions regarding the ethical issues

A. To articulate his or her unique point of view, including knowledge based on clinical and psychosocial observations -Nursing plays a unique and critical role in the resolution of difficult ethical situations. The nurse is often able to contribute information not available to others on the team, the result of the special relationship that nurses build with patients. In providing this information, it is important to remain aware of one's own values and how they may differ from those of the patient and others on the health care team.

A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply.) A. Patient will be turned every 2 hours within 24 hours. B. Patient will have normal bowel function within 72 hours. C. Patient's skin will remain intact through discharge. D. Patient's skin condition will improve by discharge.

B & C -The skin remaining intact is an appropriate goal for the patient's at-risk diagnosis. A return of normal bowel functioning is also appropriate since it indicates removal of a risk factor. Turning the patient is an intervention; skin condition improving by discharge is a poorly written goal that is not measurable.

Which of the following are examples of collaborative problems? (Select all that apply.) A. Nausea B. Hemorrhage C. Wound infection D. Fear

B & C -Hemorrhage and wound infection are collaborative problems, actual or potential physiological complications. Nurses typically monitor for these to detect changes in a patient's status. Nausea and fear are both NANDA-I approved nursing diagnoses.

A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply.) A. Maintain a neutral facial expression B. Lean forward when interacting with the patient C. Acknowledge the patient's answers through head nodding D. Limit direct eye contact

B & C -Leaning forward shows that the nurse is aware and attending to what the patient is saying. The use of head nodding regulates the interaction and makes it easier for the patient to know the nurse's responses to his comments. A neutral expression does not express warmth or immediacy, which is needed to establish a positive relationship. Good eye contact communicates the nurse's interest in what the patient has to say.

A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply.) A. The family comes to visit the patient. B. The patient expresses concern about pain control. C. The patient's vital signs change, showing a drop in blood pressure. D. The charge nurse approaches the nurse and requests a report at end of shift.

B & C -Pain control is a priority, because it is severe and affects the patient's ability to rest after surgery and be able to perform necessary activities. A change in vital signs is a priority, and the change could be related to the patient's pain. However, because of the nature of surgery, the nurse has to reassess for any bleeding, which lowers blood pressure. Attending to the family is important to lend the patient needed support, but it is not the initial priority. Finally the nurse must attend to urgent patient needs before completing a report.

In which of the following examples is a nurse applying critical thinking attitudes when preparing to insert an intravenous (IV) catheter? (Select all that apply.) A. Following the procedural guideline for IV insertion B. Seeking necessary knowledge about the steps of the procedure from a more experienced nurse C. Showing confidence in performing the correct IV insertion technique D. Being sure that the IV dressing covers the IV site completely

B & C -Seeking necessary knowledge about the steps of the procedure shows humility. The nurse recognizes that she needs clarification from a senior colleague. Another example of a critical thinking attitude is confidence. In this case confidently inserting an IV line allows the nurse to convey expertise and a sense of calm, leading the patient to trust the nurse. Following policy and procedure is an example of following standards of care, not of a critical thinking attitude. Making sure that the dressing is covered is a step in following good standards of IV care but is not a critical thinking attitude.

Ethical dilemmas often arise over a conflict of opinion. What is the critical first step in negotiating the difference of opinion? A. Consult a professional ethicist to ensure that the steps of the process occur in full. B. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma. C. Ensure that the attending physician or health care provider has written an order for an ethics consultation to support the ethics process. D. List the ethical principles that inform the dilemma so negotiations agree on the language of the discussion.

B. Gather all relevant information regarding the clinical, social, and spiritual aspects of the dilemma -Before proceeding with discussion about any difficult situation, just as in the nursing process, participants take time to gather all relevant information as insurance for reliability and validity during the discussion.

A clinic nurse assesses a patient who reports a loss of appetite and a 15-pound weight loss since 2 months ago. The patient is 5 feet 10 inches tall and weighs 135 pounds (61.2 kg). She shows signs of depression and does not have a good understanding of foods to eat for proper nutrition. The nurse makes the nursing diagnosis of imbalanced nutrition: less than body requirements related to reduced intake of food. For the goal of, "Patient will return to baseline weight in 3 months," which of the following outcomes would be appropriate? (Select all that apply.) A. Patient will discuss source of depression by next clinic visit. B. Patient will achieve a calorie intake of 2400 daily in 2 weeks. C. Patient will report improvement in appetite in 1 week. D. Patient will identify food protein sources.

B & C -With the related factor of reduced intake of food, the outcomes should focus on behaviors that reflect an increase in intake. Thus achieving an increase in calories and an improved appetite for food would be appropriate. The patient's depression probably contributes to the loss of appetite, but being able to discuss the source of depression is not an outcome for improving her baseline weight. Being able to identify protein sources would improve any knowledge deficit the patient might have but would not help her gain weight.

A nurse caring for a patient with pneumonia sits the patient up in bed and suctions the patient's airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following would be appropriate evaluative criteria used by the nurse? (Select all that apply.) A. Patient drinks contents of water glass. B. Patient's lungs are clear to auscultation in bases. C. Patient reports abdominal pain on scale of 0 to 10. D. Patient's rate and depth of breathing are normal with head of bed elevated.

B & D -The criteria of clear lung sounds and rate and depth of breathing are evaluative criteria for determining if the patient's airway is clear. Drinking the contents of the water glass is a completed intervention. The patient's report of pain is assessment data.

Which of the following outcome statements for the goal, "Patient will achieve a gain of 10 lbs (4.5 kg) in body weight in a month" are worded incorrectly? (Select all that apply.) A. Patient will eat at least three fourths of each meal by 1 week. B. Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. C. Patient will eat foods with high-calorie content by 1 week. D. Give patient liquid supplements 3 times a day.

B & D -The statement "Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week" is not singular. The statement "Give patient liquid supplements 3 times a day" is an intervention.

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which of the following describe the nurse's actions? (Select all that apply.) A. The application of the skin barrier is a dependent care measure. B. The call to the ostomy and wound care specialist is an indirect care measure. C. The cleansing of the skin is a direct care measure. D. The application of the skin barrier is a direct care measure.

B, C & D -The call to the ostomy and wound care specialist is an indirect care measure involving collaborative care. Cleansing the skin is an independent direct care measure. Applying the skin barrier is an independent nursing measure involving direct care.

Which of the following explain how health care reform is an ethical issue? (Select all that apply.) A. Access to care is an issue of beneficence, a fundamental principal in health care ethics. B. Reforms promote the principle of beneficence, a hallmark of health care ethics. C. Purchasing health care insurance may become an obligation rather than a choice, a potential conflict between autonomy and beneficence. D. Lack of access to affordable health care causes harm, and nonmaleficence is a basic principal of health care ethics.

B, C, & D -Since health care reform focuses on the public good, discussions about it inevitably involve reference to all aspects of ethical discourse. Reference to ethical principles helps to shape the discussion, even when individual values differ. Access to care is an issue of justice.

The nurse cared for a 14-year-old with renal failure who died near the end of the work shift. The health care team tried for 45 minutes to resuscitate the child with no success. The family was devastated by the loss, and, when the nurse tried to talk with them, the mother said, "You can't make me feel better; you don't know what it's like to lose a child." Which of the following examples of journal entries might best help the nurse reflect and think about this clinical experience? (Select all that apply.) A. Data entry of time of day, who was present, and condition of the child B. Description of the efforts to restore the child's blood pressure, what was used, and questions about the child's response C. The meaning the experience had for the nurse with respect to her understanding of dealing with a patient's death D. A description of what the nurse said to the mother, the mother's response, and how the nurse might approach the situation differently in the future

B, C, & D -The nurse can reflect on the effects of the treatment and what was difficult or confusing about the outcome. The nurse reviews the meaning of the experience to help improve understanding of personal comfort and competence in dealing with death and how to respond in the future. The nurse reflects on the communication approach used with the mother to consider if it was appropriate.

The nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline the nurse will follow? A. A living will allows an appointed person to make health care decisions when the patient is in an incapacitated state. B. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. C. The patient cannot make changes in the advance directive once admitted to the hospital. D. A durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

B. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state -A living will does not assign another individual to make decisions for the patient. A durable power of attorney for health care is active when the patient is incapacitated or cognitively impaired. A cognitively intact patient may change an advance directive at any time.

A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation? A. Fidelity B. Beneficence C. Nonmaleficence D. Respect for autonomy

B. Beneficence -The immunization is a clear effort to provide benefit. Beneficence refers to "doing good." Fidelity refers more to keeping promises. Nonmaleficence refers to the commitment to avoid harm. Respect for autonomy refers to the commitment to include patients in the decision-making process regarding health care plans.

A nurse checks a physician's order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. A nurse colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. The nurse's best action before giving the medication is to: A. Have the nurse colleague check the dose with her before giving the medication. B. Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects. C. Ask the nurse colleague to administer the medication to her patient. D. Administer the medication as prescribed and on time.

B. Consult with the pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects -When a nurse performs a new or unfamiliar procedure, such as giving a new medication, it is important to assess personal competency and determine if new knowledge or assistance is needed. The nurse's best action is to check with the pharmacist about the medication. Having another nurse check the dosage is appropriate if the nurse is still uncertain about the medication. Once the nurse feels prepared, the medication is administered as prescribed. You never ask a colleague to give a medication to a patient to whom you are assigned.

.The nurse reviews a patient's medical record and sees that tube feedings are to begin after a feeding tube is inserted. In recent past experiences the nurse has seen patients on the unit develop diarrhea from tube feedings. The nurse consults with the dietitian and physician to determine the initial rate that will be ordered for the feeding to lessen the chance of diarrhea. This is an example of what type of direct care measure? A. Preventive B. Controlling for an adverse reaction C. Consulting D. Counseling

B. Controlling for an adverse reaction -Anticipating the need to start the feeding at a slower rate is an example of controlling for an adverse reaction, which in this case would be a harmful or unintended effect (diarrhea) of therapeutic intervention.

A patient had hip surgery 16 hours ago. During the previous shift the patient had 40 mL of drainage in the surgical drainage collection device for an 8-hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100 mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of: A. Planning. B. Evaluation. C. Intervention. D. Diagnosis.

B. Evaluation -The patient's baseline for wound drainage was 40 mL, representing the initial assessment of the patient's wound condition. In this example the nurse is evaluating to determine if there is a change in the amount of drainage, which indicates the progress of wound healing.

A patient is being discharged after abdominal surgery. The abdominal incision is healing well with no signs of redness or irritation. Following instruction, the patient has demonstrated effective care of the incision, including cleansing the wound and applying dressings correctly to the nurse. These behaviors are an example of: A. Evaluative measure. B. Expected outcome. C. Reassessment. D. Standard of care.

B. Expected outcome -An expected outcome is an end result that is measureable, desirable, observable, and translates into observable patient behaviors. It is a measure that tells you if the educational interventions led to successful goal achievement, the patient's self-care of the wound. An evaluative measure would be the process of observing the patient. Reassessment is a behavior performed by the nurse. The type of wound cleanser and dressings would be a standard of care.

A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A. Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B. Gives a newly ordered medication before entering the order in the patient's medical record. C. Reads the orders back to the health care provider after receiving them and verifies their accuracy. D. Asks the preceptor to listen in on the phone conversation.

B. Gives a newly ordered medication before entering the order in the patient's medical record -Nurses enter orders into the computer or write them on the order sheet as they are being given to allow the read-back process to occur.

When an ethical dilemma occurs on your unit, can you resolve the dilemma by taking a vote? A. Yes because ethics is essentially a democratic process, with all participants sharing an equal voice B. No because an ethical dilemma involves the resolution of conflicting values and principals rather than simply the identification of what people want to do C. Yes because ethical dilemmas otherwise take up time and energy that is better spent at the bedside performing direct patient care D. No because most ethical dilemmas are resolved by deferring to the medical director of the ethics department

B. No because an ethical dilemma involves the resolution of conflicting values and principals rather than simply the identification of what people want to do -Voting about an outcome implies that participants simply express an opinion without regard for negotiating differences. The real goal in processing ethical dilemmas is to resolve differences, not simply to express opinion.

A patient is recovering from surgery for removal of an ovarian tumor. It is 1 day after her surgery. Because she has an abdominal incision and dressing and a history of diabetes, the nurse has selected a nursing diagnosis of risk for infection. Which of the following is an appropriate goal statement for the diagnosis? A. Patient will remain afebrile to discharge. B. Patient's wound will remain free of infection by discharge. C. Patient will receive ordered antibiotic on time over next 3 days. D. Patient's abdominal incision will be covered with a sterile dressing for 2 days.

B. Patient's wound will remain free of infection by discharge -When selecting an at-risk diagnosis, the goal is to avoid or prevent the condition at risk, in this case infection. The statement "Patient will remain afebrile to discharge" is a potential outcome measure for the goal. The patient receiving an ordered antibiotic and having the abdominal incision covered are both interventions.

A nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment? A. Agenda setting B. Problem-focused C. Objective D. Use of a structured database format

B. Problem-focused -The nurse saw the inflammation and gathered additional information to determine if a problem existed with the IV site. The data were not all objective; the patient's report of tenderness is subjective. Setting an agenda is an interview technique. The nurse was not using a structured format for her assessment.

The philosophy sometimes called the ethics of care suggests that ethical dilemmas can best be solved by attention to which of the following? A. Patients B. Relationships C. Ethical principles D. Code of ethics for nurses

B. Relationships -The foundation of the ethics of care is its attention to relationships, as distinguished from other more principal based philosophies.

While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A. The nurses forgot to document on the pulmonary system. B. The nurses were charting by exception. C. The computer is not working correctly. D. The physician does not have authorization to view the nursing assessment.

B. The nurses were charting by exception -Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits.

A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital versus one for home care? A. The goals of care will always be more long term. B. The patient and family need to be able to independently provide most of the health care. C. The patient's goals need to be mutually set with family members who will care for him or her. D. The expected outcomes need to address what can be influenced by interventions.

B. The patient and family need to be able to independently provide most of the health care -A community-based health care setting such as home health must work with patients and their families to set goals and outcomes that ultimately lead to a plan that allows them to provide the majority of care themselves. Goals of care will not always be more long term; goals will be short term and long term, depending on the patient's condition. Mutually setting goals with caregiving family members is true for any health care setting. The statement "The expected outcomes need to address what can be influenced by interventions" is incorrect; the outcomes allow you to direct your evaluation of care.

During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply.) A. Family report B. Chest x-ray film C. Physical examination with auscultation of the lungs D. Medical record summary of x-ray film findings

C & D -The family cannot provide information to reveal that the cough is a lung problem. A chest x-ray film is not a nursing assessment; if a previous chest x-ray film had been performed, the nurse could review that report to confirm a lung problem.

The nurse checks the intravenous (IV) solution that is infusing into the patient's left arm. The IV solution of 9% NS is infusing at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room, the nurse inspects the condition of the dressing and notes the date on the dressing label. In what ways did the nurse evaluate the IV intervention? (Select all that apply.) A. Checked the IV infusion location in left arm B. Checked the type of IV solution C. Confirmed from nurses' notes the time of dressing change and checked label D. Inspected the condition of the IV dressing

C & D -The evaluation of interventions examines two factors: the appropriateness of the interventions selected (whether the IV dressing was changed as the standard of care requires) and the correct application of the intervention (whether the dressing was in place and secure). Checking the IV infusion location in the left arm is an evaluation measure, and checking the type of IV solution is an assessment step to ensure that correct fluid is infusing.

What type of interview techniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply.) A. Active listening B. Open-ended questioning C. Closed-ended questioning D. Problem-oriented questioning

C & D -The nurse's technique is to ask a closed-ended question using a problem oriented approach. The patient gives a specific answer to broaden the nurse's knowledge about the character of his pain.

A nurse is sued for failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.) A. The nurse represents the plaintiff. B. The defendant must prove injury, damage, or loss. C. The person filing the lawsuit has the burden of proof. D. The plaintiff must prove that a breach in the prevailing standard of care caused an injury.

C & D -The patient as plaintiff must prove that the defendant nurse had a duty, breached the duty, and because of this breach caused the patient injury or damage.

In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.) A. The nurse who listens to lung sounds after a patient reports "difficulty breathing" B. The nurse who considers conflicting cues in deciding which diagnostic label to choose C. The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema D. The nurse who identifies a diagnosis on the basis of a single defining characteristic

C & D -When the nurse assesses edema without knowing how to assess the severity, the nurse fails to validate her assessment findings of edema, either by using a scale to measure the severity or by asking a colleague to validate her findings. In identifying a diagnosis on the basis of a single defining characteristic, the nurse prematurely closes clustering, which can lead to an inaccurate diagnosis. By listening to lung sounds after the patient reports "difficulty breathing" the nurse validates findings to make an accurate diagnosis. The nurse interprets cue clusters to make an accurate diagnosis when considering conflicting cues to make a diagnosis.

A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, "I feel funny." The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and begins the conversation by saying, "I believe that your patient is developing sepsis. I want to report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show? (Select all that apply.) A. Experience B. Ethical C. Analyticity D. Self-confidence E. Risk taking

C & D. -Among critical thinking concepts, the nurse shows analyticity (analyzing information, gathering additional findings, and sensing a problem), and self-confidence (calling the physician, which shows trust in his own reasoning). The nurse's experience would have influenced the familiarity of patient symptoms, but in this text experience is considered a component of the critical thinking model and not a concept. Acting ethically is a critical thinking standard.

While administering medications, the nurse realizes that she has given the wrong dose of medication to a patient. She acts by completing an incident report and notifying the patient's health care provider. The nurse is exercising: A. Authority. B. Responsibility. C. Accountability. D. Decision making.

C. Accountability -Accountability means that nurses are answerable for their actions. It means that they accept the commitment to provide excellent patient care and the responsibility for the outcomes of the actions in providing it. Following institutional policy for reporting errors demonstrates the nurse's commitment to safe patient care.

Which example demonstrates the nurse performing the skill of evaluation? A. The nurse explains the side effects of the new blood pressure medication ordered for the patient. B. The nurse asks the patient to rate pain on a scale of 0 to 10 before administering the pain medication. C. After completing the teaching, the nurse observes the patient draw up and administer an insulin injection. D. The nurse changes the patient's leg ulcer dressing using aseptic technique.

C. After completing the teaching, the nurse observes the patient draw up and administer an insulin injection -Evaluation is one of the most important aspects of clinical care coordination; it involves the determination of patient outcomes. Observing a patient demonstrate teaching is evaluation to ensure that he or she has understood teaching. Answer 2 is not evaluation since it occurs before administering a pain medication. The other options are interventions.

A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following is an evaluative measure used by the nurse? A. Suctioning the airway B. Sitting patient up in bed C. Auscultating lung sounds D. Patient describing type of discomfort

C. Auscultating lung sounds -Auscultation was the measure used to determine if the suctioning of the airway was effective. Suctioning and sitting the patient up are interventions. The nurse did not ask the patient or evaluate the nature of the pain.

A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. The level of critical thinking the nurse is using is: A. Commitment. B. Scientific method. C. Basic critical thinking. D. Complex critical thinking.

C. Basic critical thinking -This is an example of basic critical thinking, in which the nurse trusts that experts have the right answers for how to insert the Foley catheter and thus goes to the procedure manual. Thinking is concrete and based on a set of rules or principles.

The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview? A. Setting the stage B. Gathering information about the patient's chief concerns C. Collecting the assessment D. Termination

C. Collecting the assessment -The nurse is focusing on the patient's nutritional status and asking specific questions to assess his diet history.

The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity during their postoperative recovery. The registered nurse (RN) looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard? A. Deep B. Relevant C. Consistent D. Significant

C. Consistent -Use of the same pain scale for assessing pain acuity is an example of being consistent.

Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is: A. Need for improved bowel function related to change in diet. B. Patient needs improved bowel function related to alteration in elimination. C. Constipation related to inadequate fluid intake. D. Constipation related to hard infrequent stools.

C. Constipation related to inadequate fluid intake -Constipation related to inadequate fluid intake is an accurate NANDA-I approved nursing diagnosis with an appropriate etiology. Need for improved bowel function related to change in diet is a goal with an etiologic factor. Patient needs improved bowel function related to alteration in elimination is a goal with a diagnostic statement. Constipation related to hard infrequent stools is a nursing diagnostic label with a clinical sign.

A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: A. Data collection. B. Data clustering. C. Data interpretation. D. Making a diagnostic statement.

C. Data interpretation -In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not included a related factor.

The nursing diagnosis readiness for enhanced communication is an example of a(n): A. Risk nursing diagnosis. B. Actual nursing diagnosis. C. Health promotion nursing diagnosis D. Wellness nursing diagnosis.

C. Health promotion nursing diagnosis -A patient's readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient's motivation and desire to strengthen his health.

Which is the best method of negotiating or processing difficult ethical situations? A. Ethical issues arise between dissenting providers and can be best resolved by deference to an independent arbitrator such a chaplain. B. Since ethical issues usually affect policy and procedure, a legal expert is the best consultant to help resolve disputes. C. Institutional ethics committees help to ensure that all participants involved in the ethical dilemma get a fair hearing and an opportunity to express values, feelings, and opinions as a way to find consensus. D. Medical experts are best able to resolve conflicts about outcome predictions.

C. Institutional ethics committees help to ensure that all participants involved in the ethical dilemma get a fair hearing and an opportunity to express values, feelings and opinions as a way to find consensus -Ethics is ultimately an activity of community, resolved successfully through institutional ethics committees and not easily resolved by deference to a single expert or leader.

The nurse is assisting the patient with coughing and deep-breathing exercises following abdominal surgery. This is which priority nursing need for this patient? A. Low priority B. High priority C. Intermediate priority D. Nonemergency priority

C. Intermediate priority -Assisting the patient with cough and deep breathing is an intermediate priority. Intermediate priorities are nonemergency, nonlife-threatening actual or potential needs that the patient and family members are experiencing. Anticipating teaching needs of patients related to a new drug or taking measures to decrease postoperative complications are examples of intermediate priorities.

A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing? A. So you've had an upset stomach and began vomiting—correct? B. Have you taken anything for your stomach? C. Is anything else bothering you? D. Have you taken any medication for your vomiting?

C. Is anything else bothering you? -A probing question encourages a full description without trying to control the direction of the patient's story. It requires further open-ended statements. Confirming an upset stomach and vomiting is an example of summarizing findings. The questions about medications taken are examples of closed-ended questions that control the patient's response and do not ensure a full objective view from the patient.

The point of the ethical principal to "do no harm" is an agreement to reassure the public that in all ways the health care team not only works to heal patients but agree to do this in the least painful and harmful way possible. Which principle describes this agreement? A. Beneficence B. Accountability C. Nonmaleficence D. Respect for autonomy

C. Nonmaleficence -Nonmaleficence refers specifically to the concept of avoiding harm. Beneficence refers more to generosity and goodness, accountability to keeping promises, and respect for autonomy to the commitment by providers to include patients in decisions about all aspects of care.

In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable? A. Nurses understand the principle of autonomy to guide respect for patient's self-worth. B. Nurses have a scope of practice that encourages their presence during ethical discussions. C. Nurses develop a relationship to the patient that is unique among all professional health care providers. D. The nurse's code of ethics recommends that a nurse be present at any ethical discussion about patient care.

C. Nurses develop a relationship to the patient that is unique among all other professional health care providers -None of these options is wrong, but the point of the question is to build confidence and even pride in the value of the special body of knowledge that a nurse acquires about patients, the result of a unique relationship with them.

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which of the following patient care goals are long term? A. Patient will explain relationship of insulin to blood glucose control. B. Patient will self-administer insulin. C. Patient will achieve glucose control. D. Patient will describe steps for preparing insulin in a syringe.

C. Patient will achieve glucose control -It will take time for the patient who is medically unstable to achieve glucose control. Explaining the relationship of insulin to blood glucose control and self-administering insulin are short term goals and should be met before discharge. Describing steps for preparing insulin in a syringe is not a goal but an outcome statement for the goal that the patient will self-administer insulin.

A nursing student is talking with one of the staff nurses who works on a surgical unit. The student's care plan is to include nursing-sensitive outcomes for the nursing diagnosis of acute pain. A nursing-sensitive outcome suitable for this diagnosis would be: A. Patient will achieve pain relief by discharge. B. Patient will be free of a surgical wound infection by discharge. C. Patient will report reduced pain severity in 2 days. D. Patient will describe purpose of pain medicine by discharge.

C. Patient will report reduced pain severity in 2 days -An example of a nursing-sensitive outcome is one that is influenced and sensitive to nursing interventions. Such is the case with "reduction in pain severity." The patient achieving pain relief by discharge is a goal. The patient being free of a surgical wound infection by discharge is a medical outcome. The patient describing the purpose of pain medication by discharge is an outcome for a knowledge problem but not for the diagnosis of acute pain.

A patient is being discharged today. In preparation the nurse removes the intravenous (IV) line from the right arm and documents that the site was "clean and dry with no signs of redness or tenderness." On discharge the nurse reviews the care plan for goals met. Which of the following goals can be evaluated with what you know about this patient? A. Patient expresses acceptance of health status by day of discharge. B. Patient's surgical wound will remain free of infection. C. Patient's IV site will remain free of phlebitis. D. Patient understands when to call physician to report possible complications.

C. Patient's IV site will remain free of phlebitis -To achieve the goal of preventing phlebitis the nurse evaluates for signs of phlebitis, which include redness or inflammation. The outcome for this goal would be stated as, "IV site will show no signs of inflammation to discharge."

A nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion the nurse checks the patient's medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventive intervention? A. Tertiary B. Direct care C. Primary D. Secondary

C. Primary -An immunization is an example of a primary prevention aimed at health promotion.

The nurse enters a patient's room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? A. Meeting the patient's expressed wishes B. Indirect care measure C. Protecting a patient from injury D. Staying organized when implementing a procedure

C. Protecting a patient from injury -A common method for administering physical care techniques appropriately includes protecting you and your patients from injury, which involves safe patient handling. Transferring a patient is a direct care measure. Organization is an aspect of physical care but not an example of this nurse's action. Although meeting patient needs is important, it is not a physical care technique.

A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, "Why do we have standing orders for cases when patients develop life-threatening arrhythmias? Is not each patient's situation unique?" What is the nurse's best answer? A. Standing orders are used to meet our physician's preferences. B. Standing orders ensure that we are familiar with evidence-based guidelines for care of arrhythmias. C. Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation. D. Standing orders minimize the documentation we have to provide.

C. Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation -Standing orders are preprinted documents containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. They are common in critical care settings and other specialized practice settings in which patients' needs change rapidly and require immediate attention.

A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? A. The nurse's automobile insurance B. The nurse's homeowner's insurance C. The Good Samaritan laws, which grant immunity from suit if there is no gross negligence D. The Patient Care Partnership, which may grant immunity from suit if the injured party consents

C. The Good Samaritan laws, which grant immunity from suit if there is no gross negligence -The Good Samaritan law holds the health care provider immune from liability as long as he or she functions within the scope of his or her expertise.

The nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest? A. The nurse is making an accurate clinical inference. B. The nurse has gathered cues to identify a potential problem area. C. The nurse has allowed stereotyping to influence her assessment. D. The nurse wants to validate her information with the other nurse.

C. The nurse has allowed stereotyping to influence her assessment -The nurse is applying a stereotype about patients with back pain. An accurate clinical inference would not include the nurse's opinion. The cues suggest that the patient has acute pain, which the nurse is rejecting. Validation would involve having another nurse also assess the patient for pain.

You are the charge nurse on a surgical unit. You are doing staff assignments for the 3-to-11 shift. Which patient do you assign to the licensed practical nurse (LPN)? A. The patient who transferred out of intensive care an hour ago B. The patient who requires teaching on new medications before discharge C. The patient who had a vaginal hysterectomy 2 days ago and is being discharged tomorrow D. The patient who is experiencing some bleeding problems following surgery earlier today

C. The patient who had a vaginal hysterectomy 2 days ago and is being discharged tomorrow -The patient with the vaginal hysterectomy is stable and requires care that is within the scope of the LPN. The other three patients need a higher level of care requiring assessment, support, and teaching that are the responsibilities of the registered nurse.

Which outcome allows you to measure a patient's response to care more precisely? A. The patient's wound will appear normal within 3 days. B. The patient's wound will have less drainage within 72 hours. C. The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4. D. The patient's wound will heal without redness or drainage by day 4.

C. The patient's wound will reduce in size to less than 4 cm (1 1/2 inches) by day 4. -An outcome must have terms describing quality, quantity, frequency, length, or weight to allow for precise measurement. The statement "The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4" identifies a specific wound size, which indicates a degree of healing. The outcome statements concerning the wound appearing normal and having less drainage are vague and not measurable. The statement "The patient's wound will heal without redness or drainage by day 4" has more than one outcome.

The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case the finding of nausea is which of the following? A. An objective finding B. A clinical inference C. A validation D. A concomitant symptom

D. A concomitant symptom -A concomitant symptom is a symptom that occurs along with a primary symptom. The finding is subjective based on patient self-report. There is no clinical inference since the nurse is not trying to find the meaning of the findings. The patient is reporting nausea, but there is no validation or confirmation with another source.

The registered nurse (RN) checks on a patient who was admitted to the hospital with pneumonia. The patient is coughing profusely and requires nasotracheal suctioning. Orders include an intravenous (IV) infusion of antibiotics. The patient is febrile and asks the RN if he can have a bath because he has been perspiring profusely. Which task is appropriate to delegate to the nursing assistant? A. Assessing vital signs B. Changing IV dressing C. Nasotracheal suctioning D. Administering a bed bath

D. Administering a bed bath -The bed bath is a skill and task within the knowledge level and tasks appropriate for a nursing assistant. The other tasks are the responsibility of the RN. Assessment, dressing change, and suctioning require assessment and skill that are within the scope of practice of the RN.

What is the best example of the nurse practicing patient advocacy? A. Seek out the nursing supervisor in conflicting procedural situations B. Document all clinical changes in the medical record in a timely manner C. Work to understand the law as it applies to an error in following standards of care D. Assess the patient's point of view and prepare to articulate it

D. Assess the patient's point of view and prepare to articulate it -Seeking out the nursing supervisor, documenting clinical change in the medical record in a timely manner and working to understand the law as it applies to an error in following standards of care are not wrong; but advocacy generally refers to the nurse's ability to help speak for the patient.

Which task is appropriate for a registered nurse (RN) to delegate to the nursing assistant? A. Explaining to the patient the preoperative preparation before the surgery in the morning B. Administering the ordered antibiotic to the patient before surgery C. Obtaining the patient's signature on the surgical informed consent D. Assisting the patient to the bathroom before leaving for the operating room

D. Assisting the patient to the bathroom before leaving for the operating room -Assisting the patient to the bathroom is a skill and task within the knowledge level and tasks appropriate for a nursing assistant. The other tasks are the responsibility of the RN. The RN is responsible for patient teaching, medication administration, and surgical consents.

A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? A. Provide frequent mouth care. B. Maintain intravenous (IV) infusion at 100 mL/hr. C. Administer prochlorperazine (Compazine) via rectal suppository. D. Consult with dietitian on initial foods to offer patient. E. Control aversive odors or unpleasant visual stimulation that triggers nausea.

D. Consult with dietitian on initial foods to offer patient -Providing frequent mouth care and controlling outside stimulation that triggers nausea are independent interventions. Maintaining an IV infusion and administering the rectal suppository are dependent interventions.

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A. Avoid rushing when charting an entry. B. Use correction fluid to remove the entry. C. Draw a single line through the statement and initial it. D. Enter only objective and factual information about the patient.

D. Enter only objective and factual information about the patient -Nurses should enter only objective and factual information about patients. Opinions have no place in the medical record. Because the information has already been entered and is not incorrect, it should be left on the record. Never use correction fluid in a written medical record.

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? A. Value-belief pattern B. Cognitive-perceptual pattern C. Coping-stress-tolerance pattern D. Health perception-health management pattern

D. Health perception-health management pattern -The nurse is attempting to learn about the patient's self-report of health practices, clinic appointments, and exercise plan designed to improve his health.

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as: A. Identifying the clinical sign instead of an etiology. B. Identifying a diagnosis based on prejudicial judgment. C. Identifying the diagnostic study rather than a problem caused by the diagnostic study. D. Identifying the medical diagnosis instead of the patient's response to the diagnosis.

D. Identifying the medical diagnosis instead of the patient's response to the diagnosis -In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.

Setting a time frame for outcomes of care serves which of the following purposes? A. Indicates which outcome has priority B. Indicates the time it takes to complete an intervention C. Indicates how long a nurse is scheduled to care for a patient D. Indicates when the patient is expected to respond in the desired manner

D. Indicates when the patient is expected to respond in the desired manner -The time frame indicates when you expect a response to your nursing interventions. Time frames help to organize priorities but do not indicate which problem is most important. Time frames for outcomes are not used to gauge the time it takes to complete interventions, and they are unrelated to a nurse's work schedule.

The patient for whom you are caring needs a liver transplant to survive. This patient has been out of work for several months and doesn't have health insurance or enough cash. What principles would be a priority in a discussion about ethics? A. Accountability because you as the nurse are accountable for the well-being of this patient B. Respect for autonomy because this patient's autonomy will be violated if he does not receive the liver transplant C. Ethics of care because the caring thing that a nurse could provide this patient is resources for a liver transplant D. Justice because the first and greatest question in this situation is how to determine the just distribution of resources

D. Justice because the first and greatest question in this situation is how to determine the just distribution of resources -Accountability, respect or autonomy and ethics of care are not necessarily wrong, but they deflect attention from the less personal but more pertinent issue that is at stake in this situation: justice.

The evaluation process includes interpretation of findings as one of its five elements. Which of the following is an example of interpretation? A. Evaluating the patient's response to selected nursing interventions B. Selecting an observable or measurable state or behavior that reflects goal achievement C. Reviewing the patient's nursing diagnoses and establishing goals and outcome statements D. Matching the results of evaluative measures with expected outcomes to determine patient's status

D. Matching the results of evaluative measures with expected outcomes to determine patient's status -When interpreting findings, you compare the patient's behavioral responses and physiological signs and symptoms that you expect to see with those actually seen from your evaluation.

As the nurse, you need to complete all of the following. Which task do you complete first? A. Administer the oral pain medication to the patient who had surgery 3 days ago B. Make a referral to the home care nurse for a patient who is being discharged in 2 days C. Complete wound care for a patient with a wound drain that has an increased amount of drainage since last shift D. Notify the health care provider of the decreased level of consciousness in the patient who had surgery 2 days ago

D. Notify the health care provider of the decreased level of consciousness in the patient who had surgery 2 days ago -Decreased level of consciousness is a high priority. A high priority is an immediate threat to a patient's survival or safety such as a physiological episode of obstructed airway, loss of consciousness, or a psychological episode of an anxiety attack. Completing wound care would be the next priority, but it is not as critical as a change in consciousness. The other options are intermediate- or low-priority activities because they do not pose an immediate threat.

A patient has limited mobility as a result of a recent knee replacement. The nurse identifies that he has altered balance and assists him in ambulation. The patient uses a walker presently as part of his therapy. The nurse notes how far the patient is able to walk and then assists him back to his room. Which of the following is an evaluative measure? A. Uses walker during ambulation B. Presence of altered balance C. Limited mobility in lower extremities D. Observation of distance patient is able to walk

D. Observation of distance patient is able to walk -An evaluative measure determines a patient's response to therapy, in this case how well the patient is able to ambulate (distance walked).

Which of the following charting entries is most accurate? A. Patient walked up and down hallway with assistance, tolerated well. B. Patient up, out of bed, walked down hallway and back to room, tolerated well. C. Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. D. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.

D. Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise

The nurse writes an expected-outcome statement in measurable terms. An example is: A. Patient will be pain free. B. Patient will have less pain. C. Patient will take pain medication every 4 hours. D. Patient will report pain acuity less than 4 on a scale of 0 to 10.

D. Patient will report pain acuity less than 4 on a scale of 0 to 10 -Answer 4 is measurable because it is the only outcome statement that allows the nurse to obtain an actual measure of the patient's pain. The patient being pain free is a goal; the patient having less pain is written vaguely, and the patient taking pain medication every 4 hours is an intervention.

While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of: A. Inference. B. Diagnostic reasoning. C. Competency. D. Problem solving.

D. Problem solving -This is an example of problem solving. The nurse collects information and tries options until she is able to find a solution to the slowed infusion rate. The focus is on solving the problem with the patient's IV and not on solving the patient's health problem; thus this is not the diagnostic reasoning process.

.A goal specifies the expected behavior or response that indicates: A. The specific nursing action was completed. B. The validation of the nurse's physical assessment. C. The nurse has made the correct nursing diagnoses. D. Resolution of a nursing diagnosis or maintenance of a healthy state.

D. Resolution of a nursing diagnosis or maintenance of a healthy state -The success in meeting a goal is reflected in achieving expected outcomes—the physiological responses or behaviors that indicate that a nursing diagnosis has been resolved and the patient's health is improving.

In which of the following examples is the nurse not applying critical thinking skills in practice? A. The nurse considers personnel experience in performing intravenous (IV) line insertion and ways to improve performance. B. The nurse uses a fall risk inventory scale to determine a patient's fall risk. C. The nurse observes a change in a patient's behavior and considers which problem is likely developing. D. The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care.

D. The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care. -The nurse is explaining how to provide care on the basis of knowledge. Considering personal experience is self-regulation through reflection. Determining a patient's fall risk is evaluation, using a criteria-based screening scale. Observing a change in the patient's behavior and considering likely developments is inference, in which the nurse looks for a relationship in findings.

As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A. The patient has a defiant attitude and is demanding his test results. B. The patient appears to be upset with his nurse because he wants his test results immediately. C. The patient is demanding and complains frequently about his doctor. D. The patient stated that he felt frustrated by the lack of information he received regarding his tests.

D. The patient stated that he felt frustrated by the lack of information he received regarding his tests -This is a nonjudgmental statement regarding the nurse's observations about the patient. Documenting that the patient had a defiant attitude or was demanding and frequently complaining is judgmental, and information in the medical record should be factual and nonjudgmental. Documenting that the patient appears upset needs to be more specific regarding the reason for the patient's concern.