chapter 1&2

The nurse is communicating with a patient who voices concerns about an upcoming high-risks procedure. Which statement best demonstrates empathy?

"It must be difficult preparing for the procedure; how are you feeling?"

Which patient statement indicates a need for further discharge teaching that the vocational nurse should address?

"I have no idea of how this drug will affect me."

A patient furiously says, "My DR was so busy giving me instructions that he didn't hear what I was trying to ask him!" Which response is most empathetic?

"I'll bet that made you feel very frustrated."

After evaluating the nursing care plan, the nurse finds lack of progress toward the goal. What action should the nurse take next?

Revise the nursing interventions.

The nurse is caring for a patient who has been on antidepressants for 3 days. The patient tearfully says, "I still feel terrible. I don't think anything can help how I feel." Which response is the best?

"It must be frustrating to be going through this difficult time."

The diabetic patient who had blood drawn for an HbA1c level says, " I don't know why they want t look at my hemoglobin." Which response is most appropriate for the nurse to make?

"The HbA1c provides information relative to blood sugar levels for the last 2 to 3 months."

A female patient who has recently been diagnosed with an inoperable brain tumor asks the nurse, "Do you think God punishes us?" Which response demonstrates therapeutic communication?

"What do you think?"

What factors should the LPN/LVN consider when delegating a task to unlicensed assistive personnel (UAP)?(select all that apply )

-A need for the UAP to voluntarily accept the task delegated. -Continued accountability for the task by the LPN/LVN -An understanding that the task is in the job description of the UAP -A transfer of authority to the UAP

The newly licensed LPN/LVN demonstrates an understanding of employment opportunities when applying to a position in which areas? (select all that apply)

-An outpatient clinic -At home health care agency -A long-term care facility -an ambulatory care unit

The LPN/LVN participates in an in-service about cost containment within the health care facility. Which actions demonstrates understanding of cost-containment principles? (select all that apply)

-Asking the UAP to ensure correct charges for patient care items. -Only using necessary items for patient care. -Documenting supplies used for patients in their patients care record.

Which examples demonstrate patient care that reflects knowledge of the National Patient Safety Goals?(select all that apply)

-Assessing the patients HR prior to administration of digoxin -Performing hand hygiene prior to performing a patient assessment. -Documenting the appropriate time of medication administration.

The nurse explains to the nursing student that the application of critical thinking to patient care involves which factors? (select all that apply)

-Identification of a patient problem -Setting priorities -Use of logic and intuition -Expansion of thought beyond the obvious

Which statements demonstrates application of the nursing process? (select all that apply)

-Performing a head-to-toe assessment -Evaluating if patient goals have been met -Determining if nursing interventions need to be changed based on lack of patient progress toward meeting goals. -Ensuring that all personnel caring for the patient are implementing the care plan and working toward the same goal.

Which of the following are sources of clear guidelines for upholding clinical standards for safe and competent care? (select all that apply)

-The National Association for Practical Nurse Education and Service (NAPNES) -The National Federation of Licensed Practical Nurses, Inc. (NFLPN)

Which statements accurately describes the role of the LPN/LVN regardless of employment placement? (Select all that apply)

-Uphold clinical standards -Educate patients -Communicate effectively -Collaborate with the health care team

The nurse is assessing a group of patients. Which patient would most likely qualify for Medicaid?

A 35-year-old unemployed single mother with diabetes.

The nursing team is prioritizing the problem statement/nursing diagnosis of an overweight hospital patient. Which problem statement/nursing diagnosis would be most important for this patient?

Activity intolerance related to shortness of breath.

The LPN/LVN adheres to facility policy regarding core measures by performing which interventions during patient care?

Administering the ordered amount of insulin to a patient with type 1 diabetes.

The patient complains to the nurse that he is confused about his " deductible" that he owes the hospital. Which statement accurately explains a deductible?

An annual amount of money the patient must pay out-of-pocket for medical care.

Which foundational behavior is necessary for effective critical thinking?

An open attitude

During an intake interview, the nurse observes the patient grimacing and holding his hand over his stomach. The patient previously denied having any pain. What action should the nurse take next?

Ask the patient if he is experiencing abdominal pain.

While conducting an admission interview, the nurse questions the patient about pain. The patient responds, " No. I'm pretty wobbly." Which action should the nurse take next?

Ask the patient to clarify his meaning.

Steps of the Nursing Process in order?

Assessment, Diagnosis, Planning, Implementation, Evaluation

During a morning assessment, the nurse observes that the patient displays significant edema of both feet and ankles. Which statement best documents these findings?

Bilateral pitting edema in feet and ankles, 4mm deep, resolving in 3 seconds.

The nurse is assessing a new patient who complains of his chest feeling tight. The patient diapers a temperature of 100 F and an oxygen saturation of 89%, and expectorates frothy mucus. Which finding is an example of subjective data?

Chest Tightness

An overweight male patient rips off his hospital gown, throws it out the door, and shouts, "I'm not wearing this stupid gown! It is too small, too short, and exposes my backside to the world." Which response is most appropriate?

Confer with the patient for methods to acquire a larger gown.

The nurse is caring for a patient with a goal/outcome statement of Patient will sleep for 5 hours uninterrupted each night. Which nursing intervention should the nurse include?

Discourage daytime napping.

The long-term care facility nurse is caring for newly admitted 80-year-old patient who is depressed. Which approach is best for the nurse to employ?

Encourage the resident to engage in an activity.

The nurse is caring for a patient who states, " You are the only nurse who understands about my pain. Can't you give me an extra dose of pain medication?" How should the nurse respond to the patients request?

Explain that dosage schedules are by physicians orders.

The nurse compares the characteristics of a health maintenance organization (HMO) and a preferred provider organization (PPO). Which information should the nurse include about HMOs?

HMOs require a set fee of each member monthly.

Which area is the major focus of Healthy People 202 and the primary mechanism through which to improve the health of Americans in the second decade of the century?

Healthy lifestyle encouragement

Which term explains the type of care that addresses interventions for all dimensions of a patients life?

Holistic Care

Which is the main cost-containment component of diagnosis-related groups (DRGs)?

Hospitals treat and discharge patients quickly.

The nurse is caring for patient with pneumonia who complains of shortness of breath. Further assessment reveals an oxygen saturation of 89% on room air, 28 respirations/min with bilateral crackles in lung bases, blood pressure of 160/94, and a pulse rate of 102 beats/min. Which nursing diagnosis is priority for this patient?

Impaired gas exchange.

The charge nurse asks the new vocational nurse to start an intravenous infusion, a skill that the vocational nurse has not been taught during her educational program. How should the vocational nurse respond?

Inform the charge nurse of her lack of training in this procedure.

A patient asks the nurse what Medicare Part A covers. Which response is correct?

Medicare Part A covers inpatient hospital cost.

The nursing student demonstrates knowledge of the proper use of the ___________ when determine that it is safe to administer meperidine (Demerol) and promethazine (Phenergan) together.

Medication Reconciliation Form

The nurse is education a patient that is member of a health maintenance organization (HMO). Which information should the nurse include?

Obtain insurance approval for medical services prior to treatment.

The nurse adds a nursing order to the care plan related to a patients with a problem statement/nursing diagnosis of altered nutrition/Nutrition:Less Than Body Requirements Related to Nausea and Vomiting. Which nursing order should the nurse include in the plan of care?

Offer crackers and iced drink before each meal.

The nurse is performing an intake interview on a new resident to the long-term care facility. The nurse detects the odor of acetone from the patients breath. Which term accurately describes this assessment?

Olfaction

Which technique should the nurse employ to best assess skin turgor?

Pinch a skinfold on chest to assess for tenting.

The nurse is caring for a newly admitted patient who is describing his recent symptoms to the nurse. This scenario is an example of which type of source?

Primary

Which fundamental belief underscores the basis of the nursing process?

Recognition that all people have worth and dignity

The nurse is explaining the components of a complete problem statement/nursing diagnosis. In addition to the NANDA stem and etiology, which other component should the diagnosis include?

Signs and symptoms of the problem assessed.

The nurse ho has recently moved from Louisiana to Texas is uncertain about the LPN/LVN's role in applying the nursing process. Which source is most appropriate source for the nurse to consult?

The Texas State Board of Nursing

The nurse is completing the medication reconciliation form for a patient. Which information is most important for the nurse to include?

The patient reports taking Ginkgo blob daily for the last 6 months.

The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for Impaired Skin Integrity Related to Immobility. Which goal/outcome statement best correlates with the diagnosis?

The patient will sit in char at bedside for 15 minutes after each meal.

Which example shows that the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA)?

The student shreds any documents that contain identifying patient information before leaving the clinical facility.

The nurse is explaining differences in a therapeutic relationship and a social relationship to a patient. Which information about therapeutic relationships is most important for the nurse to include in the explanation?

Therapeutic relationships are goal directed.

Which statement explains the reason for inclusion of potential problems in the nursing care plan?

To alert nursing staff to prevent potential complications.

According to most state NPAs, the vocational nurse acting as charge nurse in a long-term care facility acts in which capacity?

Working under general supervision by the RN available on site or by phone.

The nurse explains that the term ___________ refers to the severity of illness.

acuity

When an insurance company directly reimburses a licensed health care provider for services, the form of financing is called?

fee for service

Shortness of breath due to emphysema would be a major component of the ___________ care plan.

interdisciplinary

Which statement accurately describes the primary purpose of the state nurse practice act (NPA)?

to define the scope of LPN/LVN practice.