Chapter 19_ Fundamental of Nursing

Which option correctly describes a nurse's actions? Select all that apply. One, some, or all responses may be correct. Correct answers include calling an ostomy and wound care specialist is an indirect care measure, cleansing the skin is a direct care measure, and applying a skin barrier is a direct care measure. Helping with IADLs is a direct (not indirect) care measure. Teaching a patient how to conserve energy while shopping is a direct care measure, not an indirect care measure.

Calling an ostomy and wound care specialist is an indirect care measure. Cleansing the skin is a direct care measure. Applying a skin barrier is a direct care measure. .

Place the steps in proper order for modifying the plan of care when a patient develops nausea after chemotherapy. These steps follow the sequence needed for revising/modifying an existing care plan: (1) enter data in the assessment column showing new information about the patient's nausea, (2) add the current patient condition of nausea as a nursing diagnosis, (3) select approaches for controlling environmental factors that worsen nausea, and (4) decide to use the patient's self-report of appetite and fluid intake as evaluation measures. The overall approach involves revising data; revising the nursing diagnoses, goals, and outcomes; then selecting or revising interventions; and finally choosing methods of evaluation.

1. Enter data in the assessment column showing new information about the patient's nausea. 2. Add the current patient condition of nausea as a nursing diagnosis. 3. Select approaches for controlling environmental factors that worsen nausea. 4. .Decide to use the patient's self-report of appetite and fluid intake as evaluation measures.

Which information would the nurse share with the patient when starting an intravenous (IV) medication? Select all that apply. One, some, or all responses may be correct. The nurse would share the following information: name of the medication, duration of time, physical sensations, and expected sensation if the IV site becomes inflamed. The nurse would give the necessary information to the patient related to the interventions being performed. The nurse would educate the patient about the medication that is given intravenously. The duration of the IV should also be explained so that the patient is aware of it. The nurse would also tell the patient about any sensation that might be experienced from the medication or if inflammation sets in so that it can be detected early. It is unnecessary for the patient to know which nurse will remove the IV and would not be shared with the patient.

Name of the medication that is given through the IV line Duration of time that the IV bag will last Physical sensations that the medication may cause Expected sensation if the IV site becomes inflamed

Which sequence would the nurse follow for making decisions about implementing interventions? The nurse would follow this sequence: (1) review all possible interventions for the patient, (2) review all possible consequences associated with each intervention, (3) determine the probability of possible consequences, and (4) judge the value of the consequences to the patient. When implementing interventions, first the nurse would review all possible interventions that can be applied to the patient. After that, the possible consequences for each intervention should be reviewed. The nurse would determine the probability of possible consequences. Finally, a judgment should be made regarding the consequences of the intervention on the patient's condition. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing a nursing action or skill such as those involved in medication administration.

1. Review all possible consequences associated with each intervention. 2. Review all possible interventions for the patient. 3. .Determine the probability of possible consequences. 4. Judge the value of the consequences to the patient.

Which factor would the nurse consider when making discharge plans for activities of daily living (ADLs)? Select all that apply. One, some, or all responses may be correct. The nurse would consider the following: a paralyzed patient will need permanent assistance for ADLs, patients should be encouraged to participate in ADLs, and family members can be allowed to assist the patient, as needed. A paralyzed patient has a permanent need for full assistance with ADLs. Patients like to be independent and should be allowed to participate as much as possible. If the patient wishes to be assisted by his or her family members, it can be allowed. A patient with a fractured arm will need assistance writing checks, but the question asked for ADLs, not for assistance with instrumental activities of daily living (IADLs). The statement that only a professional nurse can provide ADLs is false; many others can provide ADLs. Test-Taking Tip: The presence of absolute words and phrases can also help you determine the correct answer. If answer choices contain an absolute (e.g., none, never, only, must, cannot), be very cautious. Remember that there are not many things in the world that are absolute, and in an area as complex as nursing, an absolute may be a reason to eliminate it from consideration as the best choice. This is only a guideline and should not be taken to be true 100% of the time; however, it can help you reduce the number of choices. For this question, one of the choices can be eliminated because of the word only.

A paralyzed patient will need permanent assistance for ADLs. Patients should be encouraged to participate in ADLs. Family members can be allowed to assist the patient, as needed.

Which nursing intervention is an example of direct care for a patient? Select all that apply. One, some, or all responses may be correct. Activities such as administering medications, inserting an IV line, and counseling a patient are examples of direct care. Direct care involves activities that require direct contact between the patient and the nurse. Infection control (keeping the patient's room infection free) and keeping paperwork updated are examples of indirect care, not direct care. Test-Taking Tip: If you are unsure whether activities are direct care or indirect care, notice the object of the nurse's actions. The object or recipient of direct care is the patient. Because the room and paperwork are not the patient—even though they contribute to patient care—those actions are indirect care.

Administering medications Inserting an intravenous (IV) line Counseling the patient about required care

Which feature is true about standing orders? Standing orders allow a quick response to a rapidly changing clinical situation. Standing orders are preprinted documents that contain medical orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. Standing orders do not meet instrumental activities of daily living. Standing orders are focused on medical orders, not evidence-based guidelines for nursing care. Standing orders do not minimize documentation issues for nurses; they allow nurses to respond quickly.

Allow a quick response to a rapidly changing clinical situation.

Which action would a student nurse take when asked to perform a procedure that the student nurse has been trained in but has not performed in the hospital? Select all that apply. One, some, or all responses may be correct. Checking the hospital's procedure manual, asking an experienced nurse for supervision and guidance, and verbalizing the steps of the procedure with an instructor are actions the student nurse would take. If the student nurse feels the need for additional knowledge or assistance in performing any task, the student nurse should try to acquire knowledge about it by reading the procedure manual. This can also be done by consulting with people who are experienced in that procedure. The student nurse can also ask another nurse to supervise while performing the procedure. The student nurse can verbalize the steps of the procedure and ask an instructor for confirmation before performing the procedure. It is inappropriate for the student nurse to ask the unit manager to assign the procedure to another student nurse. Refusing to perform the procedure is unethical, especially since the student nurse has been trained in the procedure. Test-Taking Tip: As long as the nurse has been trained in a procedure, it is incorrect to ask for it to be assigned to another nurse.

Check the hospital's procedure manual to obtain more information. Ask an experienced nurse for supervision and guidance during the procedure. Verbalize the steps of the procedure with an instructor before performing it.

Which element is a chief component of the nursing process? Select all that apply. One, some, or all responses may be correct. The chief components of the nursing process are diagnosis, assessment, and implementation. Detection and identification are not elements of the nursing process. STUDY TIP: Commit the steps of the nursing process and their components to memory. Use a different colored 3 × 5-inch card or pen for each step to help stimulate your visual memory. Write the step on one side and its components on the other. Keep the cards with you to review when you have a few moments until you have all the steps and their components memorized.

Diagnosis Assessment Implementation

Which type of action would describe a nurse performing cardiopulmonary resuscitation (CPR) for a patient in cardiac arrest? Select all that apply. One, some, or all responses may be correct. CPR is an example of direct care and a lifesaving measure. Direct care is any care where the nurse is in direct contact with the patient; CPR is a type of direct care. A lifesaving measure is an action taken to maintain the patient's physiological or psychological balance. CPR is a necessary action taken to save a person's life. Counseling is used to reduce the patient's stress and improve interpersonal relationships; the nurse did not counsel the patient in this situation. Indirect care consists of an action where the nurse works for the benefit of the patient but is not in direct contact with the patient; CPR is direct care, not indirect care. Failure to obtain consent in situations other than emergencies may possibly result in a claim of battery, but this particular situation is an emergency.

Direct care Lifesaving measure

Which option is an example of a nurse managing indirect care activities? Infection control is an example of indirect care. Indirect care activities are those that the nurse performs without coming into direct contact with the patient. These activities are not necessarily performed on the patient but are meant for the betterment of the patients. Counseling the patient, administering medication, and performing lifesaving measures involve direct contact between the nurse and the patient. These are examples of direct care, not indirect care activities.

Infection control

Which intervention would the nurse perform for a patient who has developed a hypersensitivity reaction to penicillin and has developed hives? Select all that apply. One, some, or all responses may be correct. The nurse would perform the following interventions: record the reaction, inform the health care provider, administer diphenhydramine, and reassure the patient. When a patient develops a hypersensitivity reaction to a drug, the nurse would record the reaction. This helps describe the reaction and inform the other health care professionals. The health care provider should be notified of the reaction so the nurse can get further prescriptions or change the treatment. Diphenhydramine, an antihistamine and antipruritic medication, should be administered to relieve the allergic response. The patient may be worried, so the nurse should reassure the patient. Because the patient is allergic to the drug, it should be stopped. A reduced dose may also evoke the same response.

Record the reaction. Inform the health care provider. Administer diphenhydramine, as prescribed. Reassure the patient.

Which action would the nurse take when arranging supplies and equipment before administering an intravenous (IV) antibiotic to a patient? Select all that apply. One, some, or all responses may be correct. The nurse would place the supplies in a convenient location, check whether the equipment is working properly, and decide what supplies will be needed for the procedure. The nurse would place equipment in a convenient location so that it is easily available during the procedure. The nurse would check whether the equipment is working properly to avoid trouble during the procedure. The nurse also should determine what supplies might be required for the procedure so that he or she can make sure they are available if needed. Extra supplies should be kept ready but not opened unless required to avoid waste because unopened supplies can be returned to storage areas. It is important to check the availability of all required supplies in advance, so that supply problems do not arise during the procedure; the nurse cannot assume. Test-Taking Tip: For multiple-response questions, be sure to evaluate each possible response individually and not in relation to the other responses. 84%of students nationwide answered this question correctly.

Place the supplies in a convenient location. Check whether the equipment is working properly. Decide what supplies will be needed for the procedure.

When assessing a patient with a terminal illness, the nurse notes the patient's monosyllabic replies and limited eye contact. Which direct care intervention does the nurse perform? Direct care interventions are treatments nurses provide through interactions with patients or a group of patients. For example, a patient receives direct intervention in the form of medication administration, insertion of a urinary catheter, discharge instructions, or counseling during a time of grief. The other three interventions are indirect care interventions, which are described as treatments performed away from a patient but on behalf of the patient or group of patients (e.g., managing a patient's environment [safety and infection control]), documentation, and interprofessional collaboration. Ensuring privacy is managing the patient's environment. Requesting an analgesic is a treatment on behalf of the patient. Consulting a palliative care team is an example of interprofessional collaboration. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

Providing counseling

Which type of implementation skill is described when the nurse correctly administers an enema solution to a patient? Giving an enema is a psychomotor skill. Psychomotor skills require the integration of cognitive and motor activities to ensure safe intervention. Interpersonal skills require developing a trusting relationship, expressing caring, and communicating clearly with patients/families, not administering an enema correctly. Cognitive skills require problem solving and clinical decision-making, using facts and thinking strategies, not performing the skill of administering an enema. Collaborative skills involve another health care professional or consulting with another health care professional; the nurse did not consult with another health care professional in this situation.

Psychomotor

Which action would the nurse take when the patient who is nothing by mouth (NPO) (no food or fluids allowed) develops an adverse reaction to a new intravenous (IV) drug? Select all that apply. One, some, or all responses may be correct. The nurse would take the following actions: record the reaction, stop further administration of the drug, and notify the health care provider. An adverse reaction is an undesirable effect after administration of a medication. The reaction should be recorded for further reference. The nurse would stop the medication to prevent worsening of the reaction. The health care provider should be notified so that remedial measures can be taken. The patient is NPO; starting an oral drug without the health care provider's prescription is unethical and unsafe. Administering the drug after the reaction subsides may worsen the reaction and is unsafe nursing care.

Record the reaction. Stop further administration of the drug. Notify the health care provider.

Which action indicates that the nurse is using physical care techniques? A physical care technique is using safe patient-handling procedures. A common method for administering physical care techniques appropriately includes protecting the nurse and patients from injury. Meeting the patient's expressed needs is important, but it is not a physical care technique. Performing indirect care measures is not using physical care techniques; physical care techniques are a type of direct care. Providing a hand-off report is an indirect care measure, not a physical care technique. Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Take deep breaths for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.

Using safe patient-handling procedures

Which action would the nurse take when, right before starting the intravenous (IV) line, the patient needs to void (urinate)? The nurse would assist the patient to the bathroom. Before starting any intervention, the nurse would make sure that the patient is comfortable. The nurse would allow the patient to void and then begin the intervention when the patient is comfortable. Sedating the patient is unethical and unsafe. Starting the IV line immediately is not appropriate nursing practice; the patient's needs are more important than the nurse's. There is no need to insert a Foley catheter if the patient is able to void.

Assist the patient to the bathroom.

Which guideline would the nurse use to counsel a patient and family members about coping? Select all that apply. One, some, or all responses may be correct. The guidelines the nurse would use include assisting a patient and family members in accepting a change in health status, providing emotional and psychological support, assisting the patient and family in managing stress, and understanding that a patient requiring nursing counseling has normal adjustment difficulties and may be upset or frustrated. During counseling, the nurse must counsel the patient and family in accepting a change in health status. Once the change has been accepted, the patient can start taking care of him- or herself. The nurse would provide emotional and psychological support. The nurse would assist the patient and family in managing stress. A patient and family who need nursing counseling have normal adjustment difficulties and may be upset or frustrated, but they are not necessarily psychologically disabled.

Assist them to accept a change in health status. Provide emotional and psychological support. Assist the patient and family in managing stress. Understand that a patient requiring nursing counseling has normal adjustment difficulties and may be upset or frustrated.

Which implementation skill describes the nurse considering facts about nausea, the anatomy of the gastrointestinal tract, and the physical mechanisms for nausea and vomiting? The implementation skill being described is 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. Interpersonal skills involve discussions with others and developing a trusting patient relationship; interpersonal skills do not consider facts about nausea. A psychomotor skill is the actual performance of skills; psychomotor skills do not consider the physical mechanisms for nausea and vomiting. A consultative skill is obtaining information from another health care professional; a consultative skill does not consider the anatomy of the gastrointestinal tract. Test-Taking Tip: Read the entire question and all answer choices before answering the question. Do not assume that you know what the question is asking without reading it entirely.

Cognitive

Which direct care measure would the nurse be using when consulting with the dietitian and health care provider to determine the initial rate that will be prescribed for the tube feeding to lessen the chance of diarrhea? In this situation, the nurse is 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 for a tube feeding, which in this case could lead to a harmful or unintended side effect of diarrhea. Preventive nursing interventions promote health and prevent illness to avoid the need for acute or rehabilitative health care; the patient is already ill in this situation. Even though the nurse did consult, consulting is an indirect care measure; the question asked for a direct care measure. Counseling is a direct care measure but it focuses on helping patients solve problems to manage stress and facilitate interpersonal relationships; this was not done in this situation.Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point.

Controlling for an adverse reaction

Which step of the nursing process is the nurse performing when he or she asks the patient to rate pain 45 minutes after administering an analgesic? The nurse is performing evaluation. There are five steps in the nursing process: assessment, diagnosis, planning, implementation, and evaluation. Evaluation involves assessing the effectiveness of the nursing intervention performed (rating pain after an analgesic is administered). Assessment includes activities such as data collection and interviewing, not asking the patient to rate pain after a pain medication is given. Diagnosis involves identifying patient needs/problems, not asking a patient to rate pain after an analgesic. Implementation is the stage where the actual nursing interventions are implemented, not asking a patient to rate pain after an analgesic. Test-Taking Tip: If you did not read the last part of the question, you would miss that the nurse is rechecking pain based on the administration of analgesics. It is not the original assessment but a follow-up evaluation. Be sure to read the question completely and carefully!

Evaluation

Which level of prevention describes a nurse administering a vaccine to an infant? Giving a vaccination to an infant is an example of primary prevention. Primary prevention aims at health promotion and taking preventive steps before the disease or problem starts. Secondary prevention measures are taken by people who are suffering from diseases and are at risk of developing complications and involves screening, not administering vaccines. Tertiary prevention includes measures taken to minimize the harmful effects of disease or disability, not administering a vaccine. Rehabilitation is a tertiary prevention; it is not administering a vaccine.

Primary

Which information would the nurse include in a teaching session about the levels of prevention? Select all that apply. One, some, or all responses may be correct. The nurse would include the following information: primary prevention involves immunizations, health education programs, nutrition, and physical activities; secondary prevention involves early diagnosis and prompt treatment; tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation; and secondary prevention focuses on people who are experiencing health problems or illnesses. Secondary (not tertiary) prevention also focuses on people who are at risk of developing complications or worsening conditions

Primary prevention involves immunizations, health education programs, nutrition, and physical activities. Secondary prevention involves early diagnosis and prompt treatment Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation. Secondary prevention focuses on people who are experiencing health problems or illnesses. .

Which action does the nurse take right before implementing interventions? . The nurse would reassess the patient. During the initial phase of implementation, reassess the patient to confirm that the interventions are appropriate. The nurse reviews the care plan in the planning phase and evaluation, not right before implementing interventions. The nurse decides if the outcomes remain appropriate in the planning phase and evaluation, but not right before implementing interventions. Comparing assessment findings to validate existing nursing diagnoses occurs in the diagnosis phase, not right before implementing interventions.

Reassess the patient.

Which activity would the nurse perform when preparing for the implementation phase of the nursing process? Select all that apply. One, some, or all responses may be correct. Preparatory activities include reassessing the patient, organizing resources and care delivery, and reviewing and revising the existing nursing care plan. Five preparatory activities of nursing implementation include reassessing the patient, reviewing and revising the existing nursing care plan, organizing resources and care delivery, anticipating and preventing complications, and implementing nursing interventions. Focusing on preventive measures and counseling and motivating the patient are direct care implementation activities, not preparatory activities.

Reassessing the patient Organizing resources and care delivery Reviewing and revising the existing nursing care plan

Which action would be implemented when the nurse is unsure about implementing fall prevention guidelines for an older-adult The nurse would refer to the clinical practice protocol. A clinical practice protocol is a set of guidelines that helps health care providers make decisions about appropriate health care. Therefore the nurse would refer to the clinical practice protocol to know the accurate guidelines for fall prevention. Asking a colleague is not reliable. Allowing the next shift to begin the skill is unsafe and unethical. Waiting for the health care provider is unsafe and not necessary in this case.Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, unethical/unsafe responses, or degrading responses. Allowing the next shift to begin the protocol would be unethical and unsafe.

Refer to the clinical practice protocol.

Which intervention would be appropriate for a postoperative patient who is on bed rest and at risk of skin injuries after surgery? Select all that apply. One, some, or all responses may be correct. The nurse would reposition the patient frequently, administer analgesics before turning, and use pressure relief devices, if necessary. The patient is at a high risk of developing pressure injuries. Therefore the nurse would implement measures to prevent complications. Patient education should happen before surgery, when the patient is more receptive, not after surgery. After surgery, the patient may have pain and may not be able to learn because of the pain. This patient is on bed rest, so the patient cannot ambulate until the prescription is changed. STUDY TIP: Prepare for examinations when and where you are most alert and able to concentrate. If you are most alert at night, study at night. If you are most alert at 2:00 AM, study in the early morning hours. Study where you can focus your attention and avoid distractions. This may be in the library or in a quiet corner of your home. Do what is working for you. If you are distracted or falling asleep, you may want to change when and where you are studying.

Reposition the patient frequently. Administer analgesics before turning. Use pressure relief devices, if necessary.

As the nurse makes decisions about how to implement skin care for a patient, which action would the nurse implement? Select all that apply. One, some, or all responses may be correct. When making decisions about implementation, include the following: review the set of all possible nursing interventions for the patient's problem, examine all possible consequences associated with each possible nursing action, determine the probability of all possible consequences, and consider supplies/resources available for skin care. The nurse would think before acting, not act then think.

Review the set of all possible nursing interventions for the patient's problem. Examine all possible consequences associated with each possible nursing action. Determine the probability of all possible consequences. Consider supplies/resources available for skin care.

Which prevention level would describe a clinic nurse screening a patient for diabetes? Screening a patient for diabetes is secondary prevention. Secondary prevention focuses on people who are experiencing health problems or illnesses and who are at risk of developing complications or worsening conditions. It includes screening techniques and treating early stages of disease. Primary prevention is aimed at health promotion; it involves immunizations and vaccines, not screening for diabetes. Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation measures, not screening for diabetes. Screening for diabetes is not quaternary prevention.

Secondary