N266 Week 2 practice questions

Place the statements from a patient-centered interview in the correct order. 1. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 2. "Tell me what brought you to the hospital." 3. "You say you've lost weight. Tell me how much weight you have lost in the last month." 4. "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor, correct?" 5. "I have no further questions. Thank you for your patience."

1. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 2. "Tell me what brought you to the hospital." 3. "You say you've lost weight. Tell me how much weight you have lost in the last month." 4. "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor, correct?" 5. "I have no further questions. Thank you for your patience." Rationale First, introduce yourself and then focus the interview on the patient's presenting situation; this is known as a problem-focused approach . Once you know the presenting situation (in this example, the patient has lost weight), ask follow-up questions to clarify and expand your assessment. Use active listening skills, such as summarizing, to confirm your understanding. When the interview is over, thank the patient.

Which sequence would the nurse follow for making decisions about implementing interventions? 1. Determine the probability of possible consequences. 2. Review all possible interventions for the patient. 3. Judge the value of the consequences to the patient. 4. Review all possible consequences associated with each intervention.

2. Review all possible interventions for the patient. 4. Review all possible consequences associated with each intervention. 1. Determine the probability of possible consequences. 3. Judge the value of the consequences to the patient. Rationale 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 then determine the probability of possible consequences. Finally, a judgment should be made regarding the consequences of the intervention on the patient's condition.

Place the steps in the correct order the nurse would take to evaluate outcomes of care for a patient with a skin condition. 1. Compares the degree of agreement between the desired and actual condition of the skin. 2. Reviews the outcome criteria to identify the desired skin condition. 3. Tries to determine why the outcome criteria and actual condition of the skin do not agree, if goal is not met. 4. Judges the extent to which the condition of the skin matches the outcome criteria. 5. Inspects the condition of the skin.

2. Reviews the outcome criteria to identify the desired skin condition. 5. Inspects the condition of the skin. 1. Compares the degree of agreement between the desired and actual condition of the skin. 4. Judges the extent to which the condition of the skin matches the outcome criteria. 3. Tries to determine why the outcome criteria and actual condition of the skin do not agree, if goal is not met. Rationale The nurse would take the following steps: (1) reviews the outcome criteria to identify the desired skin condition, (2) inspects the condition of the skin, (3) compares the degree of agreement between the desired and actual condition of the skin, (4) judges the extent to which the condition of the skin matches the outcome criteria, and (5) tries to determine why the outcome criteria and actual condition of the skin do not agree, if goal is not met. Begin evaluation of nursing care by knowing what to look for as described in a patient's goals and expected outcomes. Then inspect the patient and determine how closely the condition matches the stated goal. Evaluate any differences between the patient's condition and the goal. If there is a difference, identify factors that interfered with achieving the patient's goal.

The nurse begins their shift with many patients requiring nursing care. Arrange the patients in the order in which the nurse would attend to them. 1. The 50-year-old patient admitted for angina pectoris a day before who is scheduled for a cardiac stress test at 5:30 p.m. 2. The 72-year-old patient who underwent coronary artery bypass surgery and is developing ventricular tachycardia at rest 3. The 8-year-old patient who underwent successful surgical repair of a ventricular septal defect and is being discharged the next morning 4. The 64-year-old patient admitted with myocardial infarction 1 day earlier; condition is stable; percutaneous coronary angioplasty is scheduled for 7:00 p.m.

2. The 72-year-old patient who underwent coronary artery bypass surgery and is developing ventricular tachycardia at rest 1. The 50-year-old patient admitted for angina pectoris a day before who is scheduled for a cardiac stress test at 5:30 p.m. 4. The 64-year-old patient admitted with myocardial infarction 1 day earlier; condition is stable; percutaneous coronary angioplasty is scheduled for 7:00 p.m. 3. The 8-year-old patient who underwent successful surgical repair of a ventricular septal defect and is being discharged the next morning Rationale The nurse performs an assessment of all the patients and identifies their needs and problems. The nurse then decides which need has to be attended to first. The priority would be to attend to a life-threatening problem. The 72-year-old patient is developing ventricular tachycardia, a lethal cardiac dysrhythmia. This patient's condition is critical and therefore should be dealt with first. The 50-year-old patient has to be prepared for the stress test before 5:30 p.m. Therefore this patient should be attended to next. The nurse should then attend to the 64-year-old patient. The patient had been admitted for myocardial infarction; the condition is stable and the patient is scheduled for surgery at 7:00 p.m. The 8-year-old patient and family have to be taught self-care measures and exercises. Because of discharge the next day, this patient could be attended to last.

The health care provider has prescribed medication for a patient. While caring for the patient, the nurse finds that the patient is allergic to this medication. The nurse informs the health care provider, and the provider prescribes a new medication. Which principle of the code of ethics has the nurse followed? A. Advocacy B. Accountability C. Responsibility D. Confidentiality

A. Advocacy Rationale The nurse is advocating for the safety of the patient. Advocacy is related to the support of a particular cause. The nurse speaks on behalf of the patient to ensure that the patient's right to safety is respected. Accountability involves answering for one's actions. The nurse is not trying to justify the actions; therefore, the principle of accountability is not applicable. Responsibility refers to a willingness to respect one's professional obligations and follow through on promises. However, the principle of advocacy is the most applicable principle. Confidentiality involves keeping the patient's personal health information private. The nurse is not trying to protect any patient-related information; therefore, the principle of confidentiality does not apply here.

Which activity is involved in the assessment phase of the nursing process? Select all that apply. One, some, or all responses may be correct. A. Asking the patient about concerns and problems B. Inquiring about the patient's current medications C. Teaching the patient and family about medications D. Asking about the patient's past and family medical history E. Determining if the patient and family understand the information about the medication

A. Asking the patient about concerns and problems B. Inquiring about the patient's current medications D. Asking about the patient's past and family medical history Rationale Assessment is the first step in the nursing process. It involves asking the patient about concerns and problems and current medications, including prescription medications and over-the-counter drugs. It also involves assessment of the patient's past and family medical history. All these assessment data are required for the next step of the nursing process. Teaching the patient and family about medications is part of the implementation phase of the nursing process. Determining whether the patient and family understand the information about medications is part of the evaluation phase of the nursing process.

Which implementation skill describes the nurse considering facts about nausea, the anatomy of the gastrointestinal tract, and the physical mechanisms for nausea and vomiting? A. Cognitive B. Interpersonal C. Psychomotor D. Consultative

A. Cognitive Rationale 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.

Which attitude is a component of critical thinking? Select all that apply. One, some, or all responses may be correct. A. Confidence B. Risk avoidance C. Fairness D. Discipline E. Curiosity

A. Confidence C. Fairness D. Discipline E. Curiosity Rationale Certain attitudes are essential for critical thinking . Confidence is the belief in oneself, one's judgment and psychomotor skills, and one's possession of the knowledge and the ability to think critically. A critical thinker deals with situations justly (fairness). Nurses should have confidence in their knowledge and abilities. Nurses should be fair in the care they provide. Discipline is using known scientific and practice-based criteria for activities such as assessment and evaluation. Curiosity helps the nurse question existing practices and improves the standard of care. Risk taking is encouraged when the critical thinker takes risks to try different ways to solve problems. However, when taking a risk, the nurse should follow safety guidelines, analyze any potential dangers to a patient, involve the patient in any decisions, and act in a well-reasoned, logical, and thoughtful manner.

Which statement describes a health promotion diagnosis, according to NANDA International (NANDA-I)? A. Describes a person's readiness to enhance specific health behaviors for well-being B. Describes human responses to health conditions that may develop in a vulnerable individual C. Describes human responses to health conditions that exist in an individual or community D. Is associated with a potential response to the health problem and can change by using specific nursing interventions

A. Describes a person's readiness to enhance specific health behaviors for well-being Rationale A health promotion nursing diagnosis is a type of nursing diagnosis that indicates a person's readiness to enhance specific health behaviors for well-being. A human response to health conditions that may develop in a vulnerable individual is a risk nursing diagnosis. A human response to health conditions that exist in an individual or community is an actual nursing diagnosis. A potential response to the health problem that can change by using specific nursing interventions is a related factor.

Which action demonstrates nursing competency when evaluating a patient? Select all that apply. One, some, or all responses may be correct. A. Examine the results of care according to clinical data collected. B. Compare achieved effects with goals and expected outcomes. C. Recognize errors or omissions. D. Understand a patient situation. E. Reflect on the situation.

A. Examine the results of care according to clinical data collected. B. Compare achieved effects with goals and expected outcomes. C. Recognize errors or omissions. D. Understand a patient situation. E. Reflect on the situation. Rationale A literature review of studies examining critical thinking indicators identified four actions that show a nurse is competent to perform evaluation: (1) examine the results of care according to clinical data collected; (2) compare achieved effects or outcomes with goals and expected outcomes; (3) recognize errors or omissions; and (4) understand a patient's situation, reflect on the situation, and correct errors.

A patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which statement regarding a breach of duty applies to this situation? Select all that apply. One, some, or all responses may be correct. A. Failure to document a change in assessment data B. Failure to provide discharge instructions C. Failure to follow the six rights of medication administration D. Failure to use proper medical equipment prescribed for patient monitoring E. Failure to notify a health care provider about a change in the patient's condition

A. Failure to document a change in assessment data E. Failure to notify a health care provider about a change in the patient's condition Rationale The failure to document a change in assessment data and the failure to notify a health care provider about a change in patient status reflect a breach of duty to the patient. A breach of duty is not doing what a reasonably prudent nurse would do under similar circumstances in the same geographic area. The patient is not ready for discharge instructions, so that would not be a breach of duty. Failure to follow the six rights of medication administration does not apply because, in this situation, the nurse is not giving medications. Failure to use proper medical equipment for patient monitoring does not apply to this situation because the patient is not on monitoring.

Which action may lead to an error in nursing diagnosis? Select all that apply. One, some, or all responses may be correct. A. Failure to seek guidance when the nurse has doubts B. Premature or early closure of clustering C. Selection of the wrong diagnostic label D. Failure to consider conflicting cues E. Validation of nursing diagnosis with patient

A. Failure to seek guidance when the nurse has doubts B. Premature or early closure of clustering C. Selection of the wrong diagnostic label D. Failure to consider conflicting cues Rationale Diagnostic errors occur because of errors in data collection, clustering, interpretation, or labeling. When formulating the diagnosis, the nurse should seek guidance from colleagues or senior staff members if there is any doubt. This helps prevent the incorrect formulation of the nursing diagnosis. Premature or early closure of clustering may lead to exclusion of important patient needs. Selection of a wrong diagnostic label or a label that is not relevant may result in a wrong diagnosis. The nurse who also considers conflicting cues in deciding which diagnostic label to choose interprets cue clusters to make an accurate diagnosis. Validating the nursing diagnosis with the patient helps prevent diagnostic errors.

Which statement describes the purpose of the incident report? Select all that apply. One, some, or all responses may be correct. A. Identifies loopholes in the operation of the health care system B. Provides good, quality health care C. Documents a patient's negative feedback related to the health care delivered D. Determines the severity of the punishment for the provider E. Identifies the need to change a procedure or policy

A. Identifies loopholes in the operation of the health care system B. Provides good, quality health care E. Identifies the need to change a procedure or policy Rationale The incident report is a description of an incident such as a fall causing an injury. Analysis of the incident or an occurrence report helps identify the trends of the system or unit operation of the health care system. This helps in patient safety and quality improvement. The incident report helps identify the need to change procedures, services, or infrastructure of a health care agency. It is an important part of the quality improvement program. The negative feedback of the patient regarding health care delivery is not recorded in the incident report. The incident report is not used to determine the severity of punishment to be delivered to the person who is responsible for the incident.

Which intervention demonstrates the nurses' s understanding of evidence-based practice when noting a slightly elevated temperature in a postoperative patient? A. Implementing a care bundle B. Posting isolation signs C. Limiting visitors to immediate family members only D. Administering a broad-spectrum antibiotic

A. Implementing a care bundle Rationale Ongoing review of the scientific literature and best practices within a health care organization may result in the development of care bundles , a type of clinical guideline. A care bundle is a group of interventions related to a disease process or condition. The interventions, when implemented together, result in better patient outcomes than when they are implemented individually. Care bundles improve quality of care while preventing the most common complications associated with their conditions or diagnoses. A care bundle for surgical site infection (SSI) prevention has been proven to significantly reduce the incidence of SSIs when implemented. Posting isolation signs or limiting visitors is not warranted by a slight increase in the patient's temperature. There is no information provided to indicate that an antibiotic is needed.

Which statement best describes a consent form? Select all that apply. One, some, or all responses may be correct. A. It may be signed by an emancipated minor. B. It protects the health care agency but not the health care provider. C. It signifies that the patient understands all aspects of the procedure. D. It signifies that the patient and family have been told about the procedure. E. It must be signed by the patient or responsible party at the health care agency, and consent may not be obtained by phone or fax.

A. It may be signed by an emancipated minor. C. It signifies that the patient understands all aspects of the procedure. Rationale An emancipated minor may sign a consent form. The consent form signifies that the patient understands all aspects of the procedure. The document protects the health care provider and agency in that it indicates that the patient knows and understands all aspects of the procedure. Only in the cases of underage children or unconscious or mentally incompetent people must a family member be aware of the procedure. The consent may be obtained by fax or phone with appropriate witnesses.

Which assessment activity reflects effective communication skills during a patient-centered interview? Select all that apply. One, some, or all responses may be correct. A. Meet and acknowledge visitors in the patient's room. B. Sit next to the patient. C. Ask the patient to summarize the discussion. D. Ask, "How would you prefer I address you?" E. Ask for permission to conduct the interview. F. Say, "Tell me how you want us to help you."

A. Meet and acknowledge visitors in the patient's room. B. Sit next to the patient. C. Ask the patient to summarize the discussion. D. Ask, "How would you prefer I address you?" E. Ask for permission to conduct the interview. F. Say, "Tell me how you want us to help you." Rationale Effective communication with patients during an assessment interview requires the following skills: Meet and acknowledge visitors in the patient's room, and learn their names and roles. Sit down next to the patient, and do not make an effort to exit the room too soon. At the end of an interview, ask the patient to summarize the discussion so that there are no uncertainties. Greet patients using their preferred name. Remember to ask the patient's permission to conduct an interview. Begin with open-ended questions that encourage patients to tell their stories.

Which outcome would be directly related to the goal of pain relief for a confused patient? A. Patient will display three or fewer nonverbal signs of discomfort. B. Patient will follow a set care routine. C. Patient will be oriented to person, time, and place. D. Patient will exit a low bed without falling.

A. Patient will display three or fewer nonverbal signs of discomfort. Rationale "Patient will express three or fewer nonverbal signs of discomfort" is an outcome directly related to the goal of pain relief. A goal is a broad statement that describes a desired change in a patient's condition or behavior. An expected outcome is a measurable criterion in the evaluation of goal achievement. In this case, the patient expressing three or fewer nonverbal signs of discomfort is a measurable criterion for evaluating pain relief. Following a set care routine is a patient goal, not an outcome. Being oriented to person, time, and place is an outcome for the confusion, not for the pain. Exiting a low bed without falling is an outcome, but it is related to a fall risk problem, not the pain.

Which expected outcome for the goal "Patient will achieve a gain of 10 pounds (4.5 kg) in body weight in a month" is written correctly? A. Patient will eat at least three-fourths of each meal by the end of 1 week. B. Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. C. Administer patient liquid supplements 3 times a day. D. Provide patient high-calorie meals 3 times a day.

A. Patient will eat at least three-fourths of each meal by the end of 1 week. Rationale Patient will eat at least three-fourths of each meal by the end of week 1 is a correctly written Specific, Measurable, Achievable, Relevant, and Timely ( SMART) outcome . "Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week" has two behaviors (verbalize relief and have no episodes); a correctly written outcome has one behavior only. "Administer patient liquid supplements 3 times a day" and "Provide patient high-calorie meals 3 times a day" are interventions, not correctly written outcomes.

The nurse manager distributes biweekly newsletters of ongoing unit or health care agency activities and posts minutes of committee meetings on a bulletin board in the staff break room. This is an example of which activity? A. Staff communication B. Problem-solving committees C. Interprofessional collaboration D. Nurse-physician collaborative practice

A. Staff communication Rationale A manager's greatest challenge, especially if a work group is large, is communicating with staff. Posting minutes in an accessible place for all staff ensures that all staff members receive the same message: the correct message. Minutes of committee meetings are usually in an accessible location for all staff to read. Being involved in a problem-solving committee involves reviewing ongoing clinical care issues, identifying problems, applying evidence-based practice in establishing standards of care, developing policy and procedures, implementing new practice approaches, resolving patient satisfaction issues, and developing new documentation tools. Interprofessional collaboration would involve the manager communicating with individuals from other disciplines. Nurse-physician collaborative practice involves collaborating with the physician on evidence-based practice issues.

Which element is necessary for the resolution of conflicting opinions? Select all that apply. One, some, or all responses may be correct. A. Strict adherence to patient confidentiality B. Patient-centered decision-making C. Identification of possible courses of action D. Presumption of goodwill on the part of all participants E. Participation of families and primary caregivers

A. Strict adherence to patient confidentiality B. Patient-centered decision-making D. Presumption of goodwill on the part of all participants E. Participation of families and primary caregivers Rationale Resolution of conflicting opinions requires strict adherence to confidentiality to protect patient information. Patient-centered decision-making helps resolve the conflict in the patient's best interest. Presumption of goodwill on the part of all participants helps foster trust among the participants. Families and primary caregivers can be included in the resolution process for better results. Identifying possible courses of action is the key step in resolving an ethical dilemma; it does not help resolve a conflict in opinions.

Which action by a registered nurse would result in both criminal and administrative sanctions against the nurse? Select all that apply. One, some, or all responses may be correct. A. Taking or selling controlled substances B. Refusing to provide health care information to a patient's child C. Reporting suspected abuse and neglect of children D. Applying physical restraints without a written health care provider's prescription E. Administering the wrong medication to a patient

A. Taking or selling controlled substances D. Applying physical restraints without a written health care provider's prescription Rationale The inappropriate use of controlled substances is prohibited by every Nurse Practice Act. A physical restraint can be applied only on the written prescription of a health care provider based on The Joint Commission and Medicare guidelines. Refusing to provide health care information to a patient's child, reporting suspected abuse and neglect of children, and administering the wrong medication to a patient would not result in both criminal and administrative sanctions against the nurse.

Which action does the nurse take to record and follow the instructions from the health care provider's telephone order? Select all that apply. One, some, or all responses may be correct. A. The nurse administers and documents the prescribed medications. B. The nurse reads back the prescription to the health care provider for verification and documents that the prescription was read back. C. The nurse records the details of the instructions and marks it as a telephone order (TO). D. The nurse confirms the patient's name, room number, and diagnosis. E. The nurse writes a narrative note that medication was administered "as per orders."

A. The nurse administers and documents the prescribed medications. B. The nurse reads back the prescription to the health care provider for verification and documents that the prescription was read back. C. The nurse records the details of the instructions and marks it as a telephone order (TO). D. The nurse confirms the patient's name, room number, and diagnosis. Rationale After confirming the patient's name, room number, and diagnosis, the nurse should always document when a medication is administered. Administering morphine without documenting it would be inappropriate. When prescriptions are given by telephone, the nurse carefully notes the prescription and reads it back to the health care provider for verification. In the report, the nurse indicates whether it is a TO or verbal order (VO) and mentions the name of the patient, complete prescribing information, name of the health care provider, and date and time of the TO or VO; the nurse also documents the prescription was read back to the provider. This is signed by the prescribing healthcare provider within a set time frame. The nurse does not just write that the medications were administered as per orders. TOs are discretely and carefully documented with specific information such as the date, time, patient, and health care provider's name. Vague documentation and informatics can lead to misinterpretation and legal claims.

Which statement describes utilitarianism? A. The value of something is determined by its usefulness to society. B. People's values are determined by religious leaders. C. The decision to perform a liver transplant depends on a measure of the moral life that the patient has led so far. D. The best way to determine the solution to an ethical dilemma is to refer the case to the attending physician or health care provider.

A. The value of something is determined by its usefulness to society. Rationale Utilitarianism specifically refers to the greatest good for the greatest number of people, where goodness is determined primarily by usefulness. The concept is easier to apply in a community where shared values allow for agreement about a definition of usefulness. Utilitarianism is not values determined by religious leaders, does not take into account the patient's previous moral life, and does not argue that the best way to determine the solution is to refer the case to the provider.

Which word does T represent in the SMART acronym as it relates to setting goals for the patient? A. Timed B. Treatment C. Therapeutic D. Thermoregulation

A. Timed Rationale The SMART acronym relates to setting patient goals and expected outcomes. In this acronym, T represents "timed," which means that each goal should include a realistic time frame. The SMART acronym does not include the words "treatment," "therapeutic," or "thermoregulation."

Which recommendation would the nurse give to a student nurse who asks for advice about how to become a successful critical thinker? Select all that apply. One, some, or all responses may be correct. A. Use known practice-based criteria for the assessment. B. Be open-minded about different interventions. C. Find solutions outside the standard routines of care while still following standards of practice. D. Be willing to recommend alternative approaches to nursing care when colleagues are having little success with patients. E. Imagine what it is like to be in the patient's situation.

A. Use known practice-based criteria for the assessment. B. Be open-minded about different interventions. C. Find solutions outside the standard routines of care while still following standards of practice. D. Be willing to recommend alternative approaches to nursing care when colleagues are having little success with patients. E. Imagine what it is like to be in the patient's situation. Rationale Using known practice-based criteria for the assessment is a component of the discipline critical thinking attitude. Being open-minded about different interventions is a component of the thinking independently critical thinking attitude. Finding solutions outside the standard routines of care while still following standards of practice is part of the creativity critical thinking attitude. Being willing to recommend alternative approaches to nursing care when colleagues are having little success with patients is an aspect of the risk taking critical thinking attitude. Imagining what it is like to be in the patient's situation is part of the fairness critical thinking attitude.

A student nurse who has not been trained to administer medications is assisting a registered nurse while caring for various patients in the general ward. Which intervention by the student nurse may result in a malpractice lawsuit? A. Collecting the vital signs of a patient B. Administering a subcutaneous injection C. Checking the body mass index of a patient D. Assisting the registered nurse with an enteral nutrition feeding

B. Administering a subcutaneous injection Rationale Student nurses should not perform tasks if they are unprepared because their actions can cause harm to patients. Administering a subcutaneous injection without proper preparation may lead to patient harm and expose the student nurse to a malpractice lawsuit . The student nurse can collect vital signs because this does not cause harm to the patient and is within the scope of practice for a student nurse. Checking the patient's body mass index is within the scope of practice for a student nurse. The student nurse can assist the registered nurse while providing enteral nutrition. Because this is done under the supervision of a licensed professional, the nurse will not face a malpractice lawsuit.

Which pattern will the nurse not include as a functional pattern in Gordon's model? A. Value-belief pattern B. Dependence-independence pattern C. Sexuality-reproductive pattern D. Activity-exercise pattern

B. Dependence-independence pattern Rationale The nurse can use two approaches for comprehensive assessment. These include using a structured database format and a problem-oriented approach. Gordon's model is an example of a structured database format. It has 11 functional health patterns that are assessed: the health perception and health management pattern, nutritional-metabolic pattern, elimination pattern, activity-exercise pattern, sleep-rest pattern, cognitive-perceptual pattern, self-perception and self-concept pattern, role-relationship pattern, sexuality-reproductive pattern, coping and stress tolerance pattern, and the value-belief pattern. The dependence-independence pattern is not a functional pattern in Gordon's model.

Which step of the nursing process is illustrated when the nurse observes the volume in a patient's surgical drainage collection device to determine if the health care provider should be notified? A. Planning B. Evaluation C. Implementation D. Diagnosis

B. Evaluation Rationale Evaluation is the action that the nurse is performing when observing the volume in the surgical drainage collection device to determine if it warrants notification of the health care provider. Planning involves generating solutions. Implementation is taking action. The diagnosis step involves analyzing cues to prioritize and hypothesize.

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

B. Offering counseling for coping C. Initiating early mobility protocols D. Instructing patients on side effects of medications E. Positioning patients to prevent pressure injury formation Rationale Offering counseling for coping, initiating early mobility protocols, instructing patients on side effects of medications, and positioning patients to prevent pressure injury formation are all examples of independent nursing interventions because they are actions that the nurse is able to carry out without the supervision, direction, or prescriptions from other health care providers. Inserting a urinary catheter is an example of a dependent nursing intervention, because this action requires a prescription from the health care provider.

When delivering patient care, which intervention does the nurse perform as part of the evaluation process? A. Performs treatment to enhance patient outcomes B. Recognizes unmet outcomes C. Chooses interventions that are evidence based D. Utilizes up-to-date approaches for delivering patient-centered care

B. Recognizes unmet outcomes Rationale The evaluation process involves gathering data to determine if previously selected interventions were successful and whether outcomes were met , and if revisions should be made. Performing treatment to enhance patient outcomes, choosing interventions that are evidence based, and utilizing up-to-date approaches for delivering patient-centered care are elements of the implementation component of the nursing process.

Which principle of critical judgment and decision making is the nurse demonstrating when identifying that the analgesic prescribed for a patient experiencing pain may cause an adverse reaction, including increasing the patient's fall risk? A. Review the set of all possible nursing interventions for the patient's problem. B. Review all possible consequences associated with each possible nursing action. C. Judge the value of the consequences to the patient. D. Determine the probability of all possible consequences.

B. Review all possible consequences associated with each possible nursing action. Rationale The nurse should exercise critical judgment and decision making while delivering each intervention. The nurse should follow the recommended tips for making decisions during implementation. One tip is to review all possible consequences associated with each possible nursing action (e.g., the nurse considers that the analgesic will relieve pain, have little or insufficient effect, or cause an adverse reaction, including sedating the patient and increasing the risk of falling). Another tip is to review the set of all possible nursing interventions for a patient's problem (e.g., for the patient's pain, the nurse considers analgesic administration, positioning and splinting, progressive relaxation, and other nonpharmacological approaches). Another tip is to judge the value of the consequence to the patient (e.g., if the administration of an analgesic is effective, the patient will probably become less anxious and more responsive to instruction and counseling). Another tip is to determine the probability of all possible consequences (e.g., if the patient's pain continues to decrease with analgesia and positioning and there have been no side effects, it is unlikely that adverse reactions will occur, and the intervention will be successful; however, if the patient continues to remain highly anxious, the patient's pain may not stay relieved, and the nurse needs to consider an alternative).

Which initial action would the nurse take when a patient's symptoms have changed from those that were recorded earlier? A. Consider them as minor symptom changes, irrelevant to nursing interventions. B. Revise patient data by noting the change. C. Continue the current treatments until there is a significant change in symptoms. D. Add new interventions for the new symptoms.

B. Revise patient data by noting the change. Rationale The nurse would revise patient data by noting the change. No status change is irrelevant. Waiting until a significant change occurs may be too late and is not the initial action the nurse would take; early reassessment and revision of the care plan is vital to status changes. Continuing current treatments, without the addition of new treatments, may not be in the best interest of the patient who has had a change in status, and it is not the initial action the nurse would take. The nurse must first revise and analyze the data before implementing new interventions; implementing new interventions is not the initial action in this scenario.

Which characteristic is an advantage of effective documentation? Select all that apply. One, some, or all responses may be correct. A. Repetition of therapy B. Saving time C. Minimizing error D. Effective continuity of patient care E. Omission of treatment

B. Saving time C. Minimizing error D. Effective continuity of patient care Rationale Effective documentation saves time in finding the patient's details, change in status, treatment plans, and treatments administered. It minimizes errors in treatment because all the details are mentioned in the document. It enhances and ensures effective continuity of patient care because relevant details, outcomes of treatment, and quality of patient care are noted. Effective documentation reduces repetition of therapy because the treatment or therapy that has been done is mentioned in the document. It also stops omission of treatment because the treatment plan is clearly mentioned in the document.

A patient dies after receiving care from the nurse. In what circumstance would the nurse be legally protected by Good Samaritan laws? A. The nurse provides standard care in the hospital setting, but the patient cannot be saved because of the severe injury. B. The nurse provides emergency care outside the hospital, performing a procedure for which the nurse has been trained. C. The nurse performs an emergency procedure that is normally outside the nurse's scope of practice because no one else is available at the scene. D. The nurse does not provide care at the scene but puts the patient in a car heading to the hospital.

B. The nurse provides emergency care outside the hospital, performing a procedure for which the nurse has been trained. Rationale Good Samaritan laws protect health care professionals from charges of negligence in providing emergency care outside of the hospital setting, assuming the health care provider is qualified to provide the care. Good Samaritan laws do not protect the nurse within the hospital setting, where standard procedures can be followed. Good Samaritan laws may not protect the nurse if performing a procedure for which the nurse is not qualified or trained. The Emergency Medical Treatment and Active Labor Act emphasizes that in case an emergency arises, the patient should not be shifted but should receive immediate quality treatment.

A senior nurse is reviewing a nurse's documentation of a patient with pneumonia, "Blood pressure is 150/90 mm Hg; pulse is 92 beats per minute, and the respiratory rate is 22 breaths per minute. The patient seems to have difficulty breathing. Sounds are produced when the patient exhales. Auscultation reveals rhonchi in the lower lung bases. Copious amounts of phlegm have been produced since morning." Which statement in the documentation is considered to be poor-quality documentation? Select all that apply. One, some, or all responses may be correct. A. Vital signs: blood pressure 150/90 mm Hg, pulse rate 92 beats per minute, and respiration 22 breaths per minute. B. The patient seems to have difficulty breathing. C. Auscultation reveals rhonchi in the lower lung bases. D. Sounds are produced when exhaling. E. Copious amounts of phlegm produced since morning.

B. The patient seems to have difficulty breathing. D. Sounds are produced when exhaling. E. Copious amounts of phlegm produced since morning. Rationale Good-quality documentation should be factual, accurate, current, complete, and organized. Using the word seems indicates the nurse is not communicating a fact; rather, the nurse's opinion is stated. The statement "Sounds are produced" indicates the nurse lacks knowledge. It should be written as "Wheezing is present while exhaling." By documenting "copious amounts," the nurse is not providing a detailed enough description of the amount, color, and consistency of the phlegm. The statement about the vital signs has all the required information accurately documented. Recording the presence of rhonchi in the lower bases of the lungs on auscultation is also a correct statement.

Which assessment finding will the nurse use to formulate a data cluster when caring for the patient admitted to the hospital with pneumonia? Select all that apply. One, some, or all responses may be correct. A. Dysuria B. Wheezing in left lung bases C. Respiration 20 breaths/min D. Weakness of the entire body E. Shortness of breath with ambulation

B. Wheezing in left lung bases C. Respiration 20 breaths/min E. Shortness of breath with ambulation Rationale A data cluster is a set of signs or symptoms gathered during assessment and grouped together in a logical way. Respiratory rate, wheezing, and shortness of breath are respiratory assessment findings that may be grouped together to manage a respiratory problem. Dysuria and weakness are not directly related to respiratory issues.

Which phase of a patient-centered interview is occurring when the nurse asks the patient several questions such as: "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?"? A. Setting the stage B. Gathering information about the patient's chief concerns C. Collecting the assessment D. Terminating the interview

C. Collecting the assessment Rationale The nurse is collecting the assessment by focusing on the patient's nutritional status and asking specific questions to assess the patient's dietary history. Setting the stage involves introducing oneself as the nurse and explaining the reason for collecting data. Gathering information about the patient's chief concerns is the working phase that involves gathering accurate, relevant, and complete information about a patient's condition. The termination stage of the interview involves summarizing the nurse's discussion with a patient and checking for accuracy of the information collected during the interview.

The nurse reviews gathered data regarding a patient's pain symptoms and compares defining characteristics of acute pain with those for chronic pain. This process helps the nurse avoid making an error in which area of the nursing diagnostic process, leading to a correct diagnosis of acute pain? A. Data collection B. Data clustering C. Data interpretation D. Making a diagnostic statement

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

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

C. Nurses develop a relationship to the patient that is unique among all professional health care providers. Rationale None of these options are incorrect, but the point of the question is to build confidence and even pride in the value of the special body of knowledge that the nurse acquires about patients as a result of the nurse's unique relationship with them. Nurses develop a special relationship with the patient that is unique among all professional health care providers, which makes their points of view extremely valuable.

Which goal is the nurse evaluating based on the following reassessment: On removal of the intravenous (IV) line from the right arm, the site was clean and dry with no signs of redness or tenderness? A. Patient expresses acceptance of health status by day of discharge. B. Patient's surgical wound will be free of drainage. C. Patient's IV site will remain free of infection. D. Patient understands when to call the health care provider to report complications.

C. Patient's IV site will remain free of infection. Rationale The nurse would evaluate the goal of patient's IV site will remain free of infection. To achieve the goal of preventing infection, the nurse evaluates for signs of infection, which include redness or tenderness. Reassessing the IV site would not address the patient's acceptance of health status, the patient's surgical wound being free of drainage, or the patient's understanding of when to call the health care provider.

Which factor is essential to a philosophy of care? Select all that apply. One, some, or all responses may be correct. A. Management of patient care B. Selection of proper interventions C. Selection of the management structure D. Selection of a nursing care delivery model E. Knowledge of roles and responsibilities of a nurse

C. Selection of the management structure D. Selection of a nursing care delivery model Rationale A philosophy of care helps support professional nursing care. Selection of the management structure and selection of a nursing care delivery model are essential to the philosophy of care. These factors help provide quality nursing care. Management of patient care is a skill required of an entry-level nurse; it is not related to the philosophy of care. Selection of proper interventions is essential for delivering patient care; it is not a factor in a philosophy of care. The knowledge of roles, responsibilities, and functions of a nurse is something nurses should possess.

Which nursing diagnosis will the nurse select when auscultating wheezing breath sounds in a patient with exercise-induced asthma when the clinic uses the International Classification for Nursing Practice (ICNP) terminology system? A. Difficulty coping B. Impaired mobility C. Impaired cardiovascular system D. Impaired respiratory system

D. Impaired respiratory system Rationale Impaired respiratory system would be the appropriate ICNP diagnosis for wheezing breath sounds. Difficulty coping is an ICNP nursing diagnosis, but it is not the appropriate diagnosis for this patient. Impaired mobility is not the correct ICNP diagnosis for this patient. Impaired cardiovascular system is not the correct nursing diagnosis for this patient based on the assessment finding.

Which statement requires correction regarding legal guidelines of handwritten documentation? A. "I should avoid using generalized, empty phrases." B. "I should put a line through errors made while recording." C. "I should record all written entries legibly and in black ink." D. "I should leave spaces with unknown information blank."

D. "I should leave spaces with unknown information blank." Rationale The nurse should not leave blank spaces while recording the patient's health information because another person may add incorrect information in the blank spaces. The nurse should draw a horizontal line in the space with a signature at the end to avoid this potential issue. The nurse should avoid using generalized, empty phrases such as "had a good day," which do not provide any information. Errors should not be erased because doing so may indicate that the nurse is hiding some evidence. Errors should be scratched out with a single line, and the nurse should sign and date it. Black ink is more legible when records are photocopied or scanned, and illegible entries may lead to misinterpretations.

Which patient scenario will the nurse address with a short-term goal in the plan of care? A. Cancer therapy B. Postamputation rehabilitation C. Diagnosed with a chronic condition D. Acute pain related to incisional trauma

D. Acute pain related to incisional trauma Rationale The patient who experiences acute pain would be appropriate for a short-term goal. A short-term goal is an objective behavior or response that the nurse expects a patient to achieve in a short time, usually less than a week. A patient who has acute pain related to incisional trauma requires short-term goals for pain relief. A patient who has undergone cancer therapy will focus more on long-term goals, rather than short-term goals. A patient who requires amputation rehabilitation will have long-term goals for rehabilitation. A patient who is diagnosed with a chronic condition will require more focus on long-term goals rather than short-term goals.

Which action is the best example of practicing patient advocacy? A. Seeking out the nursing supervisor in conflicting procedural situations B. Documenting all clinical changes in the medical record in a timely manner C. Working to understand the law as it applies to an error in following standards of care D. Assessing the patient's point of view and preparing to describe it

D. Assessing the patient's point of view and preparing to describe it Rationale None of the options are wrong. However, advocacy generally refers to the nurse's ability to help speak for the patient. By assessing and understanding the patient's point of view, the nurse is able to describe the patient's experience and be an advocate for the patient's care. Although seeking the expertise of the nursing supervisor in conflicting situations is advocating for the patient in general, this is not the best example of patient advocacy. Documenting all clinical changes in the medical record in a timely manner is a responsibility of the nurse and does promote patient advocacy in general; however, this is not the best example of specific patient advocacy. Working to understand the law as it applies to an error in following standards of care is a responsibility of the nurse and does promote patient advocacy in general; however, this is not the best example of specific patient advocacy.

Which type of care management approach coordinates and links health care services to patients and their families while streamlining costs and maintaining quality? A. Primary nursing B. Total patient care C. Team nursing D. Case management

D. Case management Rationale Case management is a care management approach that coordinates and links health care services to patients and their families while streamlining costs and maintaining quality. Case management is defined as "a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes" (The Case Management Society of America, 2012). In primary nursing, one registered nurse (RN) is responsible for a caseload of patients from admission to discharge. Total patient care is very similar to primary nursing; one nurse is responsible for all aspects of care for one or more patients during a shift. In team nursing, a team leader (the RN) delegates tasks to other members of the team.

Which task can the nurse delegate to assistive personnel (AP)? Select all that apply. One, some, or all responses may be correct. A. Perform a pain assessment. B. Document the completion of a task. C. Prepare a care plan. D. Give a bedpan to a patient. E. Monitor vital signs of a stable patient.

D. Give a bedpan to a patient. E. Monitor vital signs of a stable patient. Rationale The professional nurse in charge of patient care can decide which activities an AP performs independently and which activities to perform in partnership. An AP can be delegated the task of providing bedpans to patients when needed. Although the responsibility of assessment is with the nurse, if the patient is stable, the responsibility of monitoring vital signs can be delegated to the AP. The nurse is responsible for and should perform the assessment of a patient's ongoing status. For example, the nurse should perform a patient's pain assessment to determine if further intervention is required. The documentation of the completed tasks should be done by the nurse and not delegated to the AP. Preparing a care plan requires critical thinking skills and should be done by the nurse.

Which datum will the nurse document as subjective when assessing a patient with diabetes? Select all that apply. One, some, or all responses may be correct. A. Blood pressure of 120/78 mm Hg B. Radial pulse of 68 beats per minute C. Fasting blood glucose of 110 mg/dL D. Nausea with duration of 2 hours E. Tingling sensation in the feet

D. Nausea with duration of 2 hours E. Tingling sensation in the feet Rationale A verbal description of the patient's health is considered subjective data. These may include feelings, perceptions, and self-report of symptoms. Therefore, complaints of nausea and tingling sensations are considered subjective data. Objective data are the measurements of a patient's health status. Measurements of blood pressure, radial pulse, and fasting blood sugar levels are considered objective data.

Which action will the nurse take next when the patient whose blood sugar had been elevated on a previous test told the nurse that it was normal at home right before coming to the clinic for a follow-up visit? A. Ask if the patient would like a consult to another endocrinologist. B. Advise the patient to change the type of insulin. C. Instruct the patient to decrease the dose of insulin. D. Request a demonstration by the patient of the technique for checking blood sugar levels.

D. Request a demonstration by the patient of the technique for checking blood sugar levels. Rationale The nurse would ask the patient to show the technique for checking blood sugar levels. The nurse would try to identify the barriers when expected outcomes are not met. This patient informs the nurse that the blood sugar level was normal when checked at home. Therefore, it is very likely that the patient's technique is incorrect. The nurse would check for this before advising the patient further. It is premature to ask if the patient wants a consult from another endocrinologist; the nurse has to gather data before jumping to interventions. The nurse would not advise the patient to change the type of insulin before knowing what the real problem was and discussing this issue with the health care provider. Decreasing the insulin dose could make the problem worse and result in ineffective blood sugar control; decreasing the dose of insulin is the health care provider's decision, not the nurse's.

The nurse observes a student nurse and identifies that which action by the student reflects effective problem solving? A. Excessive thinking and talking about a patient's condition before making any care decisions B. Diagnostic reasoning C. Relying on one's inner sense D. Suggesting possible solutions

D. Suggesting possible solutions Rationale Effective problem solving requires the student nurse to obtain information that clarifies the nature of a problem, suggest possible solutions, and try the solution over time to evaluate that it is effective. In the case of patient care, a solution is an action for a problem. Excessively thinking about a patient without making any care decisions will not improve the patient's outcomes. Diagnostic reasoning is a form of decision making that involves being able to understand and think through clinical problems, gather information about the problem, analyze clues or individual cues, understand the meaning of evidence, and know when there is enough information (pattern of data) to make an accurate diagnosis. Intuition is one problem-solving approach that relies on one's inner sense; it is the ability to understand something immediately, without the need for conscious reasoning. Less experienced nurses, including students, may rely more heavily on analytic reasoning, whereas experienced nurses are more likely to use intuitive reasoning based on their clinical experiences with numerous patients.