NSG 100 Exam #1 Review Questions
The medical surgical nurse is planning the day immediately after receiving report. Which should be the primary nursing intervention when prioritizing care? A.Ascertaining interventions B.Assessing patient situations C.Analyzing collected data D.Assigning staff to patients
ANS: The first step when prioritizing care is assessment. Assessment is the process of gathering information to make decisions. Assessment includes knowing individual patients' health statuses to prepare for anticipated or unanticipated changes. Ascertaining interventions would occur after the assessment. Analyzing collected data would occur after an assessment. Assigning staff to patients would occur after knowing the number and level of caregivers available to provide care.
A patient is admitted to the hospital with pneumonia. The nurse develops a plan of care with a nursing diagnosis of Impaired Gas Exchange related to inadequate ventilation secondary to atelectasis. Which goal includes all elements of a goal statement? A.The patient will demonstrate correct use of the incentive spirometer after the teaching session. B.The patient will be given supplemental oxygen to use via nasal cannula. C.The patient will be given bronchodilators as prescribed. D.The patient will be instructed in use of the incentive spirometer every hour.
ANS: A An appropriate goal for a patient with any nursing diagnosis includes a subject and verb and is both measurable and patient centered. The statement of the patient demonstrating the correct use of incentive spirometry after a teaching session meets these requirements. It is also realistic and relevant. Providing supplemental oxygen, administering bronchodilators, and instructing on the incentive spirometer are all nursing interventions, not goals.
Universal precautions are used in the care of all hospitalized patients regardless of their diagnosis or possible infection status A.True B.False
ANS: A Because we do not always know if a person has an infectious disease, Universal or standard precautions are applied to every person every time to assure that transmission of disease does not occur.
Which statement best describes the evaluation phase of the nursing process? A.Evaluation is performed throughout all phases of the nursing process. B.Evaluation is performed only after nursing interventions are performed. C.Evaluation focuses on determining changes and preventing complications. D.Evaluation is determined based on gathering subjective and objective data.
ANS: A Evaluation is performed throughout all phases of the nursing process. It is a constant, fluid process that is used to determine the effectiveness of planned interventions and includes reassessment of the patient. It is not only performed after nursing interventions. Implementation focuses on determining changes and preventing complications. Assessment is based on gathering subjective and objective data.
The nurse is preparing to discharge a patient after a hospital stay. Which task should the nurse perform to determine if goals have been met? A.Collect data related to the goal and make decisions about nursing care effectiveness. B.Collect data to develop new nursing diagnoses for the home health nurse to follow. C.Collect data to provide discharge instructions to follow when at home. D.Collect data related to patient-specific outcomes for accrediting bodies.
ANS: A Outcomes are evaluated to determine if the patient's goals have been met and for the effectiveness of the plan of care. Based on the evaluation, the plan of care is continued, modified, or terminated. The nurse will collect data at discharge to determine if the goals have been met and make decisions about nursing care effectiveness. If home health care is ordered at discharge, the home health nurse will develop a plan of care pertinent to self-care. The nurse provides discharge instructions based on healthcare provider orders, but this is not related to nursing diagnoses. The hospital will collect data for accrediting agencies, but this is not related to the nursing diagnoses and goal attainment.
During the process of reflection, what is the most appropriate question for a nurse to ask himself or herself? A."What could I have done differently?" B."What's going on right now?" C."How can the patient's status change?" D."What should I do to communicate this information?"
ANS: A Reflection is the action of retrospectively making sense of occurrences, experiences, situations, or decisions and learning from them. What did or did not work? What could have been done differently to achieve better outcomes?
The nurse is reviewing assessment data collected from a patient with pneumonia. Which data should the nurse identify as subjective? A.Report of difficulty breathing B.Presence of cough C.Observation of yellow sputum D.Rapid breathing
ANS: A Subjective data are those that the patient feels, such as difficulty breathing. Objective data are those that the nurse can observe, measure, feel, hear, or smell.
The nurse is caring for a client experiencing urinary retention. Which preventive catheter-associated urinary tract infection (CAUTI) measure should the nurse take to protect the client from a urinary tract infection (UTI)? A.Consider an alternative to an indwelling catheter. B.Obtain a urine sample for a urinalysis. C.Review the criteria for catheter insertion. D.Initiate an antibiotic before inserting a catheter.
ANS: A The alternative to an indwelling catheter is to use intermittent straight catheterization to relieve urinary retention. Using intermittent straight catheterization allows the bladder to fill and completely empty more normally, maintaining physiologic function. Obtaining a urine sample for a urinalysis will not address the problem of urinary retention. Reviewing the criteria for catheter insertion is a preventive CAUTI measure, but urinary retention is one of the criteria for urinary catheterization. Initiating an antibiotic before inserting a catheter is unnecessary and contributes to the development of antibiotic-resistant organisms.
The nurse is working with an adult patient with a diagnosis of posttraumatic stress disorder (PTSD). The patient shares that he has begun exercising daily at a local gym, which lowers his daily stress level. Which type of nursing diagnosis would best capture the patient's exercise behavior? A.Health promotion diagnosis B.Syndrome diagnosis C.Actual diagnosis D.Risk diagnosis
ANS: A The patient has already modified his behavior to improve his well-being and health status; a health promotion diagnosis would be appropriate. A risk diagnosis is used to capture patient risk factors for illness or alterations in health. A syndrome diagnosis is a type of nursing diagnosis that may be used when a cluster of nursing diagnoses will help improve patient outcomes if addressed at the same time. An actual describes human response to health conditions or life processes.
The nurse prioritizes care for a patient who is recovering from a below the knee amputation secondary to complications of diabetes mellitus. Which intervention is identified as the priority for this patient using Maslow's hierarchy of needs? A.The nurse teaches the patient how to properly change dressings on the right-leg amputation site. B.The nurse teaches the patient proper home safety techniques to prevent diabetic wounds. C.The patient joins the local American Diabetes Association support group. D.The patient attends classes to deal with body image.
ANS: A When prioritizing care based on Maslow's hierarchy of needs, physiological needs will come before safety, social, and esteem needs. Caring for an amputation site is meeting a physiological need. Attending a class to deal with body-image issues addresses an esteem need. Teaching the patient about safety techniques to prevent diabetic wounds addresses a safety need. Joining a support group meets an esteem need.
The nurse is teaching a new nurse about developing an appropriate nursing diagnosis for a patient. Which information should the nurse use to accurately describe nursing diagnosis? (Select all that apply.) A.Nursing diagnosis describes responses to a health problem. B.A nursing diagnosis is a condition that nurses are licensed to treat. C.A nursing diagnosis is a clinical judgment. D.Nursing diagnosis is flexible and changes based on patient responses. E.Nursing diagnosis is uniform between patients.
ANS: A,B,C,D A nursing diagnosis is a statement of nursing judgment (clinical judgement); a condition that nurses, by virtue of their education, experience, and expertise, are licensed to treat; and a description of the physical, sociocultural, psychologic, and spiritual responses to an illness or health problem. Nursing diagnosis is flexible because nursing diagnoses can change as the patient's response changes. A medical diagnosis is determined by a physician, can only be treated by a physician, and is a disease process or pathophysiological response that is uniform between patients. Medical diagnosis is constant for as long as the disease process is present in the patient. Results for item 5. 5
The nurse is caring for a patient with an MRSA infected leg wound. Which of the following precautions would the nurse anticipate using in the care of the patient? (select all that apply) A.Proper handwashing and use of gloves B.Use of disposable gown C.Patient placement in an airborne infection isolation room (AIIR) D.Use of disposable or dedicated patient-care equipment E.Don mask upon entry into the patient room
ANS: A,B,D Contact Precautions are used for patients with known or suspected infections that represent an increased risk for contact transmission such as MRSA. Contact precautions include: Private room; use of PPE appropriately, including gloves and gown, use disposable or dedicated patient-care equipment. Masks are required PPE for Droplet precautions and an airborne infection isolation room (AIIR) is required for patients with known or suspected pathogens transmitted by the airborne route.
The nurse has assessed a patient and determined the appropriate nursing diagnoses. Which activity should the nurse perform next? (Select all that apply.) A.Write down the desired goals. B.Set priorities and goals in collaboration with the patient. C.Reassess the patient to update the database. D.Write priority nursing interventions. E.Relate nursing actions to patient outcomes.
ANS: A,B,D Once the assessment and diagnostic phases of the plan of care are completed, the nurse can perform the planning phase. This includes specifying patient goals/desired outcomes, and related priority nursing interventions. Reassessing the patient to update the database to keep it updated is a step for the implementation phase and relating nursing actions to patient outcomes is an activity for the evaluation phase. All other activities can be related to the planning phase.
The nurse is formulating a plan of care for a patient who is diagnosed with cancer. Which factor related to patient goals should the nurse consider? (Select all that apply.) A.Goal/outcomes should center on the patient. B.Goal/outcomes should be measurable. C.Goal/outcomes should indicate whether treatment is successful. D.Goal/outcomes should be attainable. E.Goals/outcomes may address multiple actions.
ANS: A,B,D The patient is always the subject of the goal/outcome and requires a specific, single action to ensure that all nurses understand what the patient needs to do to achieve a goal. Goal/outcomes should be measurable, attainable, relevant, and time-limited. An evaluation, not a goal/outcome statement, will indicate whether interventions were successful.
The nurse reviewed data collected on a patient. Which reason should the nurse keep in mind for developing the plan of care? (Select all that apply.) A.Ensures individualized patient-centered care B.Ensures continuity of care through communication for all involved in the patient's care C.Serves as a comprehensive document that includes information for all patient treatments, procedures, and medications D.Serves as a guide to assign nursing staff to care for each patient
ANS: A,B,D The purpose of nursing plans of care is to provide: (1) individualized patient-centered care to meet the needs of the patient, (2) a guide to assign nursing staff to care for each patient, (3) health insurance companies documented proof for reimbursement for services rendered to the patient, and (4) continuity of care through communication for all involved in the patient's care. Additionally, nursing plans of care inform the nurse about specific observations or actions that need to be documented. The nursing plan of care is not a comprehensive document that lists all treatments, procedures, and medications.
The nurse is prioritizing patient care as low, medium, or high priority for the current assignment. Which patient should the nurse identify as having a high-priority circumstance? (Select all that apply.) A.A patient with emphysema and a pulse oximeter reading of 88 (impaired gas exchange) B.A patient who is receiving a blood thinner (Risk for bleeding) C.A confused older patient (Acute confusion) D.A patient who is experiencing bouts of diarrhea E.A patient with congestive heart failure and shortness of breath (Ineffective breathing pattern)
ANS: A,B,E High-priority circumstances include patients with a risk for bleeding, such as a patient receiving blood thinners such as warfarin (Coumadin), patients with ineffective breathing patterns, and patients with impaired gas exchange. A confused patient and a patient with diarrhea would have medium-priority circumstances.
Which of the following data are considered subjective? A.The patient complaint of lower back pain B.The patient blood pressure of 118/76 C.Patients reported history of pneumonia D.Diagnostic study results
ANS: A,C Subjective data (what the client says) includes: Client thoughts, beliefs, feelings, sensations, and perceptions. Information from the Client Health History. Objective data (direct measurements or observation) includes findings from Nursing Physical Examination and diagnostic studies
Which of the following are clinical signs and symptoms of a systemic infection? A.Fever B.Edema C.Malaise D.Pain or tenderness E.Tachycardia
ANS: A,C,E Signs and symptoms associated with a systemic infection include fever and chills, fatigue/malaise, nausea and vomiting, fast heart rate (tachycardia), headache. Signs and symptoms associated with localized infections generally include redness, warmth, swelling/edema and pain or tenderness.
Which of the following best describe the purpose of assessment? (Select all that apply) A.Determine a patients current and ongoing health status B.Select interventions to address patients' needs C.Communicate goals of care D.Identify patient health risks and health-promotion activities
ANS: A,D Assessment is the systematic and continuous collection of data about a patient for the purpose of determining the patient's current and ongoing health status, predicting the patient's health risks, and identifying appropriate health-promoting activities. Assessment establishes a data base about the patient's perceived needs, health problems, and responses to these problems
A nurse in a long-term care facility is interviewing a new resident. Which question should the nurse ask to assess the client's risk of infection? A."How would you rate your level of stress?" B."How long did you live in your previous home?" C."Are you a high-school graduate?" D."How have your previous infections been treated?"
ANS: A,D The nature, number, and duration of physical and emotional stressors can influence susceptibility to infection. Asking about previous infections and their treatment will give helpful information to assess the client's risk of infection. The facts about education, and residence are not relevant.
The nurse develops a nursing diagnosis of Self-Care Deficit related to the patient's inability to perform activities of daily living (ADLs) related to left-sided weakness secondary to cerebrovascular accident. Which component of the nursing diagnosis was noted? (Select all that apply.) A.Diagnostic label B.Variations C.Data clusters D.Etiology E.Defining characteristics
ANS: A,D,E There are three components to a nursing diagnosis: diagnostic label, etiology, and defining characteristics. The etiology is the cerebrovascular accident. The diagnostic label is the self-care deficit. The defining characteristic is the patient's inability to perform ADLs due to left-sided weakness. Variations are used when additional information is needed to make the diagnosis clearer and patient-specific. Data clusters are created when analyzing assessment information prior to beginning to write a nursing diagnosis.
Which one of the following nursing interventions is an indirect care intervention? A.A nurse explains available birth control measures to a young couple. B.A nurse meets with the collaborative care team to plan nursing measures for a patient. C.A nurse prays with a patient prior to surgery. D.A nurse administers pain medication to a patient with end-stage renal cancer.
ANS: B An indirect care intervention is treatment performed away from the patient but on behalf of a patient or group of patients, such as the example in answer B, consulting with the collaborative care team. The remaining answer options are direct care interventions or treatment performed through interaction with the patient.
A nurse is admitting a client who reports increased thirst and fatigue. Which of the following actions should the nurse include in the assessment step of the nursing process? A.Take action to restore the client's health. B.Ask the client when the condition started. C.Reach a conclusion about the client's health status. D.Set goals for the client's recovery.
ANS: B Assessment is the first step of the nursing process, where the nurse gathers subjective and objective information about the client's condition.
Performing hand hygiene after removing gloves with alcohol-based hand sanitizer is recommended to prevent the spread of C. diff. A.True B.False
ANS: B Because alcohol does not kill C. diff spores, use of soap and water is more effective than alcohol-based hand rubs.
A client with Parkinson disease is working to improve fine motor skills, especially for completing activities of daily living. Which intervention would be considered a collaborative intervention? A.Provide assistance as needed with dressing and grooming. B.Reinforce education on the use of assistive devices provided by physical therapy. C.Make sure lighting and space are adequate for the client. D.Administer medications to improve muscle tone.
ANS: B Collaborative interventions are actions the nurse carries out with other health team members such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships among, healthcare personnel. Providing assistive devices and educating the client on their proper use would fall into the discipline of physical/occupational therapy, although the nurse will have to assist with reinforcing the teaching and information. Providing assistance and attending to the client's space would be independent interventions. Administering medications would be a dependent intervention.
Entering a room at 2:00 am, a nurse notes that the patient is not in bed; the patient is sitting in the chair and states that she is having difficulty sleeping. Employing critical thinking, the nurse responds by: A.Assisting the patient back into bed B.Asking more about the patient's sleep problem C.Positioning the patient and providing a warm blanket D.Obtaining an order for a hypnotic medication
ANS: B Critical thinking involves collecting, interpreting, analyzing, drawing conclusions first prior to acting. A, C and D are interventions.
The nurse is assessing a child who reports feeling "sick." The nurse understands that the majority of childhood illnesses such as the common cold are caused by which type of organism. A.Parasite B.Virus C.Bacteria D.Influenza
ANS: B Infections are a normal part of childhood, and most children experience some kind of infection from time to time. The majority of these infections are caused by viruses, and for the most part they are transient and relatively benign and can be overcome by the body's natural defenses and supportive care. Bacteria, influenza, and parasites are not the reason for common infections seen in childhood.
Isopropyl alcohol is an example of a disinfectant, a chemical preparation used on inanimate objects to destroy pathogens A.True B.False
ANS: B Isopropyl alcohol and chlorhexidine are examples of Antiseptics, a chemical preparation used on skin or tissue to inhibit the growth of microorganisms. Chlorine (Bleach) and Phenol are examples of disinfectants
Which of the following best describes the function of normal flora in the human body? A.Directs immune system components to injury or infection sites B.Usually do not cause disease but protect individuals from pathogenic organisms. C.Recognizes and responds to antigens D.Bars invading microorganisms unless it is physically disrupted
ANS: B Normal flora usually do not cause disease but help to maintain health. The number and variety of flora maintain a sensitive balance with other microorganism. Normal flora can inhibit pathogens. The Inflammatory process directs immune system components to injury or infection sites. The immune system recognizes and responds to antigens. The skin bars invading microorganisms unless it is physically disrupted
The nurse is planning care for a new patient with unstable blood glucose levels. Which should be the priority action by the nurse? A.Establish a specific nursing diagnosis. B.Complete an assessment on the client. C.Create a plan of nursing care for the client. D.Carry out solutions to manage the problem.
ANS: B The five steps of the nursing process are assessment, diagnosis, planning implementation, and evaluation. The nurse should first perform a thorough assessment and then create a nursing diagnosis based on the assessment data. The nurse should then create a plan of care with nursing interventions to address the diagnosis, follow the plan, and then evaluate the effectiveness of the nursing interventions.
The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which goal statement represents a properly stated outcome/goal? A.The client will turn in bed every 2 hours. B.The client will have healthy, intact skin during hospitalization. C.The client will report the importance of applying lotion to skin daily. D.The client will use a pressure-reducing mattress.
ANS: B The goal or outcome should state the opposite of the nursing diagnosis stem. Turning in bed is an intervention that may result in achieving the goal. Applying lotion is an intervention that may result in achieving the goal. Healthy, intact skin is the reverse condition of impaired skin integrity. Using a pressure-reducing mattress is an intervention that may result in achieving the goal.
Which of the following actions by the nurse demonstrates the evaluation step of the nursing process? A.Draw a conclusion after noting a client has 4+ pitting edema of the lower extremities and decreased urine output. B.Check and document a client's pain level 30 min after administering pain medication. C.Review the results of blood glucose drawn before a client ate breakfast. D.Administer an antibiotic to a client who has an infected wound.
ANS: B The nurse is evaluating, which is the final step of the nursing process, to determine if the pain medication administered to the client is effective. Evaluation is the same as assessment; however, to determine the client's status and progress, evaluation is performed.
The nurse is implementing care for patients in an acute care facility and asks a patient about dietary restrictions related to religion or ethnicity. Which nursing goal is the nurse meeting with this question? A.Follow prescribed dietary needs. B.Provide culturally competent care. C.Determine need for special services. Promote contentment in the patient.
ANS: B The nurse should ask about dietary preferences related to religion and ethnicity to provide culturally competent care. The nurse would discuss dietary needs that relate to disease processes with the healthcare provider. The nurse would communicate the needs for special services through the healthcare provider. The nurse would ask the patient about food preferences to promote contentment in the patient.
Which period is the stage of disease during which the patient begins to present general signs and symptoms? A.Incubation period B.Prodromal stage C.Full stage of illness D.Convalescent period
ANS: B The patient begins to present general signs and symptoms during the prodromal stage. The patient may be most infectious during the prodromal stage when early signs and symptoms of the disease are present but are often vague and nonspecific. During this stage, the patient often does not realize he or she is contagious and spreads the infection as pathogens continue to multiply Incubation period: organisms growing and multiplying. Prodromal stage: person is most infectious, vague and nonspecific signs of disease Full stage of illness: presence of specific signs and symptoms of disease Convalescent period: recovery from the infection
During which stage of infection is the patient generally most contagious? A.Incubation period B.Prodromal stage C.Full stage of illness D.Convalescent period
ANS: B The patient is most infectious during the prodromal stage when early signs and symptoms of the disease are present but are often vague and nonspecific. During this stage, the patient often does not realize he or she is contagious and spreads the infection.
A nurse completes an initial assessment of a client. The nurse clusters related data, recognizes a pattern, signs and symptoms and determines a diagnosis. The nurse is engaged in which step of Tanner's clinical judgment model? A.Noticing B.Interpreting C.Responding D.Reflecting
ANS: B The step of interpreting in Tanner's clinal judgment model includes: Comparing and contrasting data, clustering related information, recognizing inconsistencies, checking accuracy and reliability, distinguishing relevant from irrelevant information and determining the importance of information
Which of the following are examples of nurse initiated (independent) nursing interventions? (Select all that apply.) A.Medication administration B.Medication teaching C.Patient positioning Family teaching
ANS: B,C,D Independent nursing interventions do not require an order from another health care professional. Examples of independent nursing interventions include patient positioning and education. Administering medication requires an order from a physician or other health care professional.
Which of the following should be the nurse's actions following the collection of assessment data? (Select all that apply.) A.Identifying strengths and resources B.Analyzing the data for gaps and inconsistencies C.Clustering cues to generate tentative hypotheses D.Comparing the data with suspected medical problems E.Measuring the data against standards to identify significant cues
ANS: B,C,E Once assessment data are collected, the nurse begins the process of data analysis. This process includes three steps: comparing data against standards to identify significant cues, clustering cues to generate tentative hypotheses, and identifying gaps and inconsistencies. Listing client strengths and resources occurs later in the process of writing a nursing diagnosis. Comparing data with medical problems is not done when analyzing collected data.
A nurse is developing a nursing diagnosis for a client. Which information should she include? A.Actions to achieve goals B.Expected outcomes C.Factors influencing the client's problem D.Nursing history
ANS: C A nursing diagnosis is a written statement describing a client's actual or potential health problem. It includes a specified diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the planning step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process.
The registered nurse (RN) is explaining Tanner's clinical judgment model to a student nurse. Which element should the RN explain is needed first to make a clinical judgment? A.Intuition B.Initiation of practice C.Nursing school education D.Multiple years of experience
ANS: C According to Tanner's clinical judgment model, thinking like a nurse begins with nursing education, which teaches fundamental nursing skills and knowledge. Intuition develops from experience and nursing knowledge over time. Initiation of practice does improve critical thinking skills but is not the initiating factor.
Which of the following nursing diagnoses is written correctly? A.Risk for constipation R/T decreased daily activity and medication use AEB abdominal pain and hard formed stool B.Breast Cancer R/T to family history C.Imbalanced Nutrition R/T insufficient funds in meal budget AEB body weight 20% below ideal weight. D.Deficient Knowledge R/T inaccurate follow through of instructions
ANS: C Answer A is an actual problem not risk, answer B is a medical diagnosis, and answer D inaccurate follow through of instructions is a defining characteristic Etiology is missing from statement. (ie: R/T alteration in memory, insufficient knowledge od resources)
Which of the following is not an element in the development or chain of infection? A.Means of transmission B.Infectious agent C.Formation of immunoglobin D.Reservoir for pathogen growth
ANS: C Links in the chain if infection include Infectious agent, Reservoir, Portal of Exit and Entry, Means of Transmission and Susceptible host. The Formation of immunoglobin (antibodies) occurs with the immune system response. Immunoglobins or antibodies act as a critical part of the immune response by specifically recognizing and binding to particular antigens, such as bacteria or viruses, and aiding in their destruction.
Which of the following statements includes the essential components of a well written goal? A.The patient will use the 4-prong walker he brought from home correctly B.The nurse will teach the patient the correct use of walker within 2 days C.By end of this week, patient will demonstrate correct use of the walker each time he ambulates D.In the next few weeks, patient will demonstrate safe ambulation with the walker he brought from home
ANS: C S: Single specific M: Measurable A: Attainable (Achievable) R: Relevant T: Time limited
A patient presents to the emergency department (ED) complaining of pain and burning on urination. The patient also tells the triage nurse that she noted blood in the urine the past few times she urinated, so she thought she should come to the emergency department. In which category should the nurse classify the patient's problem to prioritize care in relation to other patients in the ED? A.Urgent B.Emergent C.Nonurgent D.Immediate
ANS: C Symptoms indicate that this patient may be experiencing a urinary tract infection, which would be considered nonurgent since a delay in treatment would not result in a life-threatening situation. It would not meet the criteria for urgent or emergent/immediate.
A patient's surgical wound has become swollen, red, and tender. The nurse notes that the patient has a new fever and leukocytosis (elevated WBCs). The priority intervention is to: A. Use surgical technique to change the dressing B.Reassure the patient and recheck the wound later C.Notify the health care provider and support the patient's fluid and nutritional needs D.Alert the patient and caregivers to the presence of an infection to ensure care after discharge
ANS: C The client's symptoms are suggestive of a possible respiratory infection such as pneumonia. A sputum specimen may be ordered to determine which infectious microorganism may be present and which antibiotics to use to treat the infection. A bronchoscopy may be done when infection or tumors are suspected or to remove secretions from the bronchial tree; however, it will not be performed first. A CT scan might be indicated if the client does not respond to other treatment. A urinalysis would not be indicated as the patient's symptoms are not consistent with a urinary tract Infection.
The nurse is assessing a patient who reports shortness of breath, fever, and a productive cough. Which diagnostic test would the nurse anticipate being ordered? A.Bronchoscopy B.CT scan C.Sputum culture and sensitivity D.Urinalysis
ANS: C The client's symptoms are suggestive of a possible respiratory infection such as pneumonia. A sputum specimen may be ordered to determine which infectious microorganism may be present and which antibiotics to use to treat the infection. A bronchoscopy may be done when infection or tumors are suspected or to remove secretions from the bronchial tree; however, it will not be performed first. A CT scan might be indicated if the client does not respond to other treatment. A urinalysis would not be indicated as the patient's symptoms are not consistent with a urinary tract Infection.
A patient who admits to smoking two packs of cigarettes a day is diagnosed with lung cancer based on his symptoms and a series of test results. Which of the following is the etiology in this scenario? A.Lung cancer B.Test results C.Smoking cigarettes D.The subjective and objective data
ANS: C The etiology is the factor that maintains the unhealthy condition (smoking cigarettes). Lung cancer is the problem, and the remaining factors are the distinguishing characteristics.
The nurse determines that the patient has not met the plan of care for the nursing diagnosis Skin Integrity, Impaired because the wound has not healed within the time frame specified. The nurse chooses to revise the plan of care. Which step should the nurse perform first? A.Talk to the healthcare provider. B.Set a new, reachable goal. C.Reassess the wound. D.Change the interventions.
ANS: C The nurse should always reassess the patient prior to changing the plan of care. This determines future needs. The nurse would not need to discuss this with the healthcare provider because these are nursing interventions. The nurse may need to change interventions or set new goals, but these are not the first steps.
Which of the statements best describes the purpose of the nursing process? A.Deliver care to a client in an organized way. B.Implement a plan that is close to the medical model. C.Identify client needs and deliver care to meet those needs. D.Make sure that standardized care is available to clients.
ANS: C The purpose of the nursing process is to diagnose and treat human responses to actual or potential health problems. Simply described as identifying a client's actual or potential healthcare problems or needs, establishing plans to meet the identified needs, and delivering specific nursing interventions to meet those needs. The Nursing Process is the framework within which nurses provide care to patients in an organized and effective manner, it is not the purpose. The nursing process is not part of the medical model. The nursing process is individualized for each client's care plan. It is not about standardizing care.
Systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health best describes: A.Critical Thinking B.Clinical Reasoning C.Clinical Judgement D.Nursing Process
ANS: D According to NANDA, the nursing process is a five-part systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health. ACEN defines critical thinking as, the deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information that is both factual and belief-based. Clinical reasoning-thinking process by which a nurse reaches a clinical judgement. A clinical judgment is the nurse's determination and provision of appropriate care to the patient, refers to the result (outcome) of critical thinking or clinical reasoning-the conclusion, decision, or opinion made.
Which of the following definitions best describes Critical Thinking? A. The thinking process by which a nurse reaches a clinical judgement. B.The result (outcome) of critical thinking or clinical reasoning-the conclusion, decision, or opinion made C.Systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health. D.The deliberate nonlinear process of collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating information.
ANS: D Critical thinking is a broad/umbrella term that includes reasoning outside and inside of the clinical setting. Definition is from The Accreditation Commission for Education in Nursing (ACEN). Critical thinking skills are necessary for sound clinical decision making. Clinical Reasoning is the thinking process by which a nurse reaches a clinical judgement. Clinical Judgement refers to the result (outcome) of critical thinking or clinical reasoning-the conclusion, decision, or opinion made. Nursing Process: Five-part systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health. (NANDA: North American Nursing Diagnosis Association)
The nurse is discussing interventions to prevent infection with a group of new colleagues. Which statement indicates that this discussion has been effective? A."Limiting exposure to the client to every 2 hours decreases the spread of infections." B."The use of personal protective equipment is the main way to reduce the spread of infection." C."Wearing gloves is the best way to reduce the spread of infection." D."Proper hand hygiene is the key to reducing the spread of infection."
ANS: D Hand hygiene is identified as the best way to prevent the spread of infection. Wearing gloves as a part of standard precautions is effective; however, doing so does not replace hand hygiene. It is unrealistic to limit client care to every 2 hours. Personal protective equipment is an approach to reduce the spread of infection; however, it does not replace hand hygiene.
The nurse on a surgical unit has evaluated that patient outcomes per the nursing care plan have not been met. Which action should the nurse take? A.Confront the patient on missing target goals. B.Immediately call the healthcare provider. C.Abandon the care plan. D.Reassess and revise the care plan.
ANS: D Nursing plans of care are created and implemented by nursing. If goals are not met, the nurse reassesses and revises the plan of care; the nurse does not abandon the plan of care. The healthcare provider does not need to be urgently notified of nursing care plan goal changes, nor is the patient confronted in a hostile manner. Mutual goal setting and communication with the patient will support meeting care goals.
An alert, oriented patient is admitted to the hospital with chest pain. From whom should the nurse collect primary data on this patient? A.Family member B.Physician C.Another nurse D.Patient
ANS: D Primary data consist of information obtained directly from a patient.
A client with an upper respiratory infection is receiving radiation treatments. What is the reason the nurse explains the risk of infection to the client? A.Radiation only kills the targeted cells. B.Radiation is lethal to only cancerous cells. C.Radiation is only destructive to tissue. D.Radiation kills both cancerous and healthy cells.
ANS: D Some medical therapies may predispose an individual to infection. Radiation treatments for cancer destroy not only cancerous cells but also some normal cells, thereby rendering the client more vulnerable to infection.
A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates the use of critical thinking skills? A.Administer an influenza vaccine after asking a client about allergies. B.Check a client's armband before dispensing daily thyroid medication to a client who has hypothyroidism. C.Give a client who has type 1 diabetes mellitus her morning dose of insulin after checking her blood glucose level. D.Intervene after reviewing arterial blood gas results for a client who is on mechanical ventilation.
ANS: D The nurse is using critical thinking when analyzing a client's critical issues and then planning to intervene with an appropriate action.
The nurse is explaining how to develop an appropriate nursing diagnosis. Which participant statement indicates an appropriate understanding? A."A nursing diagnosis is developed after the nurse evaluates the interventions provided." B."A nursing diagnosis is derived after the nurse develops the plan of care for the patient." C."A nursing diagnosis is determined by the medical diagnosis and current patient needs." D."A nursing diagnosis is based on clinical judgment that is derived from assessment data."
ANS: D The nursing diagnosis is derived after collecting objective and subjective data from the patient and defining the patient problem. A nursing diagnosis is determined by using clinical judgment. The evaluation phase occurs after the interventions are provided. The nursing diagnosis is derived prior to developing the plan of care for the patient, not after. The nursing diagnosis is not necessarily based on the medical diagnosis. Nursing diagnoses may result from the complications that arise from medical problems.
Which patient should the nurse assess first after receiving the change-of-shift report? A.A patient with type 1 diabetes mellitus with blood glucose of 82 mg/dL (range 70-130mg/dL) B.A patient with hypertension with a blood pressure of 168/88 mmHg (normal BP less than 120mmHg/less than 80mmHg) C.A patient with a bowel obstruction who is complaining of nausea D.A patient with heart failure who is complaining of shortness of breath
ANS: D Using the ABCs (airway, breathing, and circulation) as a guide, the nurse should first assess the patient with shortness of breath. This would take priority over a patient complaining of nausea, a patient with an elevated (but not critically elevated) blood pressure, and a patient with a normal blood glucose reading.
