Ch18- EAQ

Which action describes an independent nursing intervention? Select all that apply. One, some, or all responses may be correct. 1 Inserting a urinary catheter 2 Offering counseling for coping 3 Initiating early mobility protocols 4 Instructing patients on side effects of medications 5 Positioning patients to prevent pressure injury formation

2,3,4,5

Which patient problem would be a high priority? 1 Risk of skin breakdown 2 Need for rehabilitation 3 Mild anxiety 4 Chest pain

4

Which action would the nurse perform first when he or she 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? 1 Reconnect the drainage tubing. 2 Inspect the condition of the IV dressing. 3 Improve the patient's comfort and turn to the side. 4 Obtain the next IV fluid bag from the medication room.

1

Which priority level would be assigned to the patient diagnosed with decreased gas exchange? 1 High 2 Low 3 Medium 4 Intermediate

1

Which word does the letter "T" represent in the SMART acronym as it relates to setting goals for the patient? 1 Timed 2 Treatment 3 Therapeutic 4 Thermoregulation

1

Which intervention performed by the nurse would require an order from a health care provider? Select all that apply. One, some, or all responses may be correct. 1 Getting an x-ray of the chest to rule out pulmonary complications 2 Administering an antibiotic to prevent infection 3 Starting an intravenous (IV) infusion of normal saline 4 Instructing the patient to splint the incision when coughing 5 Teaching the patient about the side effects of the medication

1,2,3

Which intervention performed by the nurse is an independent nursing intervention? Select all that apply. One, some, or all responses may be correct. 1 Teaching the patient about deep-breathing exercises 2 Starting an intravenous (IV) infusion 3 Administering analgesic medications 4 Assisting the patient in taking a bed bath 5 Repositioning a patient for relief from pain

1,4,5

Which type of problem is a high priority? 1 One related to nonurgent needs of the patients 2 One related to life-threatening needs of the patients 3 One focused on the patient's long-term health care needs 4 One focused only on the physiological diagnosis

2

Which patient outcome about a wound would allow the nurse to measure a patient's response to care more precisely? 1 Will appear normal within 3 days. 2 Will have less drainage within 72 hours. 3 Will reduce in size to less than 4 cm (1.5 inches) by day 4. 4 Will heal without redness or drainage by day 4.

3

Which intervention performed by the nurse is an interdependent intervention? Select all that apply. One, some, or all responses may be correct. 1 Preparing the patient for diagnostic tests 2 Administering medications to the patient 3 Consulting with a physiotherapist for postoperative exercises 4 Collaborating with the home health department to ensure the patient will have home health visits 5 Conferring with the unit discharge coordinator to help the patient return home

3,4,5

Setting a time frame for outcomes of care determines which purpose? 1 The priority level 2 Time it takes to complete an intervention 3 How long the nurse is scheduled to care for a patient 4 When the patient is expected to respond in the desired manner

4

Which criterion is used to evaluate efficacy of interventions? 1 Consultation 2 Critical thinking 3 Communication 4 Expected outcome

4

Which expected outcome is written in measurable terms? 1 Patient will be pain free. 2 Patient will have less pain. 3 Patient will take pain medication every 4 hours. 4 Patient will report pain acuity less than 4 on a scale of 0 to 10.

4

Which outcome is correctly written and would the nurse add to the plan of care about the patient's apical pulse? 1 The patient will have a normal apical pulse. 2 The patient's apical pulse values will be stable. 3 The patient will have acceptable apical pulse values. 4 The patient's apical pulse will be at least 70 beats per minute.

4