NR224: Week 1

Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?

"Validation involves comparing data with other sources for accuracy."

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take?

Assist the patient with comfort measures.

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent?

Back

A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel?

Changing the patient's position

A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information?

Perform a thorough nursing health history.

Which method of data collection will the nurse use to establish a patient's database?

Performing a physical examination

The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?

Place pillow under the patient's abdomen after turning

A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse's action?

Prevention of joint contractures

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?

Problem-oriented assessment

A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe?

Reduced errors of omission

A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?

Renal calculi

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record?

Reports to third-party payers

Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.)

Tense muscles Reactive responses Trouble concentrating Very tired feelings

A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to follow up?

The new nurse charts consecutively on every other line.

A nurse is charting. Which information is critical for the nurse to document?

The patient received a pain medication, Lortab

Which goal is most appropriate for a patient who has had a total hip replacement?

The patient will walk 100 feet using a walker by the time of discharge

The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?

The patient's room with the door closed

A nurse is assessing body alignment. What is the nurse monitoring?

The relationship of one body part to another while in different positions

A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene?

The student nurse shares patient information with a friend.

The nurse is caring for an older-adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings?

These are common manifestation with UTIs.

The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?

"What reasons do you think are contributing to your fatigue?"

Which entry will require follow-up by the nurse manager? (Jane More)

0830

A nurse is using focused charting. Match the chart entry to the correct letter of the acronym. a. Applied oxygen, stayed with patient, and instructed to slow breathing. b. Patient states, "feel better," respirations 16 with O2 saturations 96%. c. Patient states, "can't catch my breath and chest hurts." Confused.

1. C 2. A 3. B

Upon assessment a nurse discovers postural abnormalities on several patients. Match the abnormalities to the findings the nurse observed.

1. Lordosis E) Exaggeration of anterior convex curve of lumbar spine 2. Kyphosis F) Increased convexity in curvature of thoracic spine 3. Scoliosis A) Lateral-S- or C-shaped spinal column with vertebral rotation 4. Genu valgum B) Legs curved inward so knees come together as person walks 5. Genu varum C) One or both legs bent outward at knee 6. Torticollis D) Inclining of head to affected side

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN,

In which order will the nurse use the nursing process steps during the clinical decision-making process? 1. Evaluating goals 2. Assessing patient needs 3. Planning priorities of care 4. Determining nursing diagnoses 5. Implementing nursing interventions

2, 4, 3, 5, 1

The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one?

3, 4, 1, 5, 6, 2

The nurse is caring for a patient who is immobile and needs to be turned every 2 hours.The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?

A foot cradle

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing?

A minimum data set

Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan?

A patient who is not completely immobile

A nurse is providing care to a group of patients. Which patient will the nurse see first?

A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea

A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care?

A patient with neck surgery

The nurse is caring for a patient with a spinal cord injury and notices that the patient's hips have a tendency to rotate externally when the patient is supine. Which device will the nurse use to help prevent injury secondary to this rotation?

A trochanter roll

A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete?

A verbal report

Which action should the nurse take to best develop critical thinking skills?

Actively participate in clinical experiences.

While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take?

Adapt the positioning technique to the situation.

A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient?

Altered nutrient metabolism

The nurse is caring for a patient who has had a stroke causing total paralysis of the right side.To help maintain joint function and minimize the disability from contractures, passive ROM will be initiated. When should the nurse begin this therapy?

As soon as the ability to move is lost

A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?

Ask about the chief concerns or problems.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make?

Ask the NAP to record the patient's vital signs before administering medications.

The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation?

Ask the patient about the crying.

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations?

Ask the patient about the facial grimacing with movement.

While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?

Ask the patient about usual sleep patterns and the onset of having difficulty resting.

While completing an admission database, the nurse is interviewing a patient who states "I am allergic to latex." Which action will the nurse take first?

Ask the patient to describe the type of reaction.

A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility?

Asking for an orientation to the unit

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

Asking the patient what pain-relief methods, pharmacological and non-pharmacological, have worked in the past

The nurse is preparing to lift a patient. Which action will the nurse take first?

Assess weight and determine assistance needs.

The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient?

Assist with ambulation and measure how far the patient walks

A nurse is providing care to a group of patients. Which situation will require the nurse to obtain a telephone order?

At 0100, a patient's blood pressure drops from 120/80 to 90/50, and the incision dressing is saturated

The patient is being admitted to the neurological unit with a diagnosis of stroke. When will the nurse begin discharge planning?

At the time of admission

The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take when assessing the respiratory system?

Auscultate the entire lung region to assess lung sounds.

A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?

Blood pressure cuff

The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding?

Both feet are supported on the floor with ankles flexed.

A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take?

Chart on the computer immediately after care is provided.

A nurse is charting on a patient's record. Which action will the nurse take that is accurate legally?

Charts legibly

A nurse is describing the purposes of a health care record to a group of nursing students.Which purposes will the nurse include in the teaching session? (Select all that apply.)

Communication Legal documentation Reimbursement Research Education

A patient is being discharged home. Which information should the nurse include?

Community resources

A nurse is evaluating care of an immobilized patient. Which action will the nurse take?

Compare the patient's actual outcomes with the outcomes in the care plan.

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Completes a comprehensive database

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs?

Concept mapping

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Consider cultural differences during this assessment.

Which action should the nurse take when using critical thinking to make clinical decisions?

Consider what is important in a given situation.

Upon assessment a nurse discovers that a patient has erythema. Which actions will the nurse take? (Select all that apply.)

Consult a dietitian. Increase frequency of turning. Place on pressure-relieving mattress.

Which behavior indicates the nurse is using a team approach when caring for a patient who is experiencing alterations in mobility?

Consults physical therapy for strengthening exercises in the extremities

A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation?

Creativity

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using?

Critical pathway design

The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?

Dangle the patient at the bedside.

A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIEcharting?

Demonstrated use of crutches

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking?

Determining the degree to which standards of care are met by reviewing patients' health records

The nurse is caring for a patient who has had a recent stroke and is paralyzed on the left side. The patient has no respiratory or cardiac issues but cannot walk. The patient cannot button a shirt and cannot feed self due to being left-handed and becomes frustrated very easily. The patient has been eating very little and has lost 2 lbs. The patient asks the nurse, "How can I go home like this? I'm not getting better." Which health care team members will the nurse need to consult? (Select all that apply.)

Dietitian Physical therapist Occupational therapist Psychologist

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day3, and the patient cannot sit in the chair. What should the nurse do?

Document the variance in the patient's record.

A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?

Each movement is moved just to the point of resistance by the nurse.

A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse find?

Electronic health record

The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan?

Encourage the patient to perform as many self-care activities as possible

A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?

Establish goals that are measurable and realistic.

A patient continues to report post-surgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first?

Explore other options for pain relief.

A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?

Focus on the patient's presenting situation.

The nurse is caring for a patient with impaired physical mobility. Which potential complications will the nurse monitor for in this patient? (Select all that apply.)

Footdrop Hypostatic pneumonia Impaired skin integrity

The nurse is admitting a patient who has been diagnosed as having had a stroke. The health care provider writes orders for "ROM as needed." What should the nurse do next?

Further assess the patient.

The nurse is observing the way a patient walks. Which aspect is the nurse assessing?

Gait

Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)

Gives a change-of-shift report to the oncoming nurse about the patient Reads the progress notes of assigned patient's record

A nurse wants to find the daily weights of a patient. Which form will the nurse use?

Graphic record and flow sheet

The nurse is providing teaching to an immobilized patient with impaired skin integrity about diet. Which diet will the nurse recommend?

High protein, high calorie

A nurse is completing an OASIS data set on a patient. The nurse works in which area?

Home health

A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session?

Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care

A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up?

If a nurse has computer competency, the nurse is competent in informatics.

A nurse is assessing pressure points in a patient placed in the Sims' position. Which areas will the nurse observe?

Ileum, clavicle, knees

A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?

Imbalance

A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)

Implement an automatic sign-off. Use a programmed speed-dial key when faxing Impose disciplinary actions for inappropriate access Shred papers containing personal health information (PHI).

Which action demonstrates a nurse utilizing reflection to improve clinical decision making?

Improves a plan of care while thinking back on interventions effectiveness

A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following?

Institutional practice guidelines

The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill?

Interpretation

The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use?

Lateral position

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?

Left knee incision 1 inch in length without redness, drainage, or edema

A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse consider?

Loss of hope

The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient?

Low-molecular-weight heparin doses

A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene?

Making a clinical decision based on previous shift assessments

The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the nurse take?

Measure the calf circumference of both legs.

A nurse developed the following discharge summary sheet. Which critical information should the nurse add?

Mode of transportation

A nurse is caring for a patient with osteoporosis and lactose intolerance. What will the nurse do?

Monitor intake of vitamin D.

A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?

Moves patient's arm until thumb is upward and lateral to head with elbow flexed

A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise?

Nurse's assumptions about hospital discharge

A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)

Patient describing excitement about discharge Patient's expression of fear regarding upcoming surgery

A nurse is conducting a nursing health history. Which component will the nurse address?

Patient expectations

A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?

Patient is lying on side.

The nurse is gathering data on a patient. Which data will the nurse report as objective data?

Respirations 16

A nurse is using the critical thinking skill of evaluation. Which action will the nurse take?

Review the effectiveness of nursing actions

A nurse is preparing to document a patient who has chest pain. Which information is criticalfor the nurse to include?

Sharp pain of 8 on a scale of 1 to 10

After providing care, a nurse charts in the patient's record. Which entry will the nurse document?

Skin pale and cool

A nurse is using a critical thinking model to provide care. Which component is first that helps a nurse make clinical decisions?

Specific knowledge base

Which action indicates a registered nurse is being responsible for making clinical decisions?

Takes immediate action when a Pt. condition worsens

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage.

A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?

The nurse speaks only to the patient's daughter.

A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?

The patient is apprehensive about discharge.

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?

Upon admission

The patient is unable to move self and needs to be pulled up in bed. What will the nurse do to make this procedure safe?

Use a friction-reducing device

A nurse is assessing the skin of an immobilized patient. What will the nurse do?

Use a standardized tool such as the Braden Scale

The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the nurse use for logrolling?

Use at least three people.

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?

Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.

A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions?

Uses critical thinking for the highest level of quality nursing care

Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions?

Using the nursing process

A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal?

When observed laterally, the spinal curves align in a reversed "S" pattern.

A nurse is completing an assessment using the PQRST to obtain data about the patient's chest pain. Match the questions to the components of the PQRST that the nurse will be using. a. Where is the pain located? b. What causes the pain? c. Does it come and go? d. What does the pain feel like? e. What is the rating on a scale of 0 to 10? 1. Provokes 2. Quality 3. Radiate 4. Severity 5. Time

b & 1 d & 2 a & 3 e & 4 c & 5