Exam 1 - MedSurg

The nurse is assigned to care for a newly admitted patient. Number in order the steps for using the nursing process to prioritize care (Number 1 is the first step, and number 5 is the last step.) __Evaluate whether the plan was effective. __Identify any health problems. __Collect patient information. __Carry out the plan. __Determine a plan of action.

1. Collect patient information. 2. Identify any health problems. 3. Determine a plan of action. 4. Carry out a plan. 5. Evaluate whether the plan was effective.

An example of a nursing activity that reflects the ANA definition of nursing is: A. diagnosing a patient with a feeding tube as being at risk for aspiration. B. establishing protocols for treating pts in the ED C. providing antianxiety drugs for a patient who has disturbed sleep patterns. D. identifying and treating dysrhythmias that occur in a patient in the coronary care unit.

A

The nurse is caring for a diabetic patient in the ambulatory surgical unit who has just undergone debridement of an infected toe. Which task is most appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? A. Check the patient's vital signs. B. Evaluate the patient's awareness. C. Monitor the site of the patient's IV catheter. D. Evaluate the patient's tibial and pedal pulses.

A

The nurse's role in addressing the National Patient Safety Goals established by The Joint Commission includes (select all that apply): A. using side rails and alarm systems as necessary to prevent patient falls. B. memorizing and implementing all the rules published by The Joint Commission. C. verifying telephone and verbal orders using the "write down and read back" procedure. D. encouraging patients to be actively involved in and question their own health care. E. obtaining a complete list of the patient's medications and monitoring their use throughout the continuum of care.

A B C

A patient has a nursing diagnosis of ineffective airway clearance related to retained secretions, excessive mucus, and ineffective cough as evidenced by adventitious breath sounds. What should the nurse include in the NCP as an appropriate NOC outcome and NIC intervention for this nursing diagnosis? A) Aspiration Prevention (NOC) and Aspiration Procedures (NIC) B) Respiratory Status: Gas Exchange (NOC) and Oxygen Therapy (NIC) C)Respiratory Status: Ventilation (NOC) and Respiratory Monitoring (NIC) D) Respiratory Status: Airway Patency (NOC) and Airway Management (NIC)

Answer: d Rationale: If ineffective airway clearance is the nursing diagnosis, the outcome (NOC) would be focused on airway patency with interventions (NIC) focusing on airway management. The problem identified is not associated with aspiration, poor gas exchange, or impaired ventilation.

The linkages among NANADA-I nursing diagnoses, NOC patient outcomes, and NIC nursing interventions can be used to: A. evaluate patient outcomes. B. provide guides for planning care. C. predict the results of nursing care. D. shorten written care plans for individual patients.

B

A nurse is providing care to a patient after right hip surgery. Within a pay-for-performance system, a critical role of the nurse is to: A. ensure that care is provided using a minimal amount of supplies. B. discharge the patient at completion of the number of approved days of care. C. implement measures to decrease the risk of the patient acquiring an infection. D. assess the patient's ability to pay for health care services at the time of admission.

C

A nurse is working on the medical-surgical unit at an urban hospital would like to become certified in a medical-surgical specialty. The nurse knows that this process would most likely require: A. a bachelor's degree in nursing. B. formal education in advanced nursing practice. C. experience for a specific period in medical-surgical nursing. D. membership in a medical-surgical nursing specialty organization.

C

When using evidence-based practice, the nurse: A. must use clinical practice guidelines developed by national health agencies. B. should use findings from randomized controlled trials to plan care for all patient problems. C. uses clinical decision making and judgment to determine what evidence is appropriate for a specific clinical situation. D. statistically analyzes the relationship of nursing intervention to patient outcomes to establish evidence for the most appropriate patient interventions.

C

Advantages of the use of informatics in health care delivery are (select all that apply): A. reduced need for home care nurses in rural areas. B. increased patient anonymity and confidentiality. C. the ability to achieve and maintain high standards of care. D. improved communication of the patient's health status to the health care team. E. access to standardized plans of care that are available for most types of health problems.

C D E

In identifying patients at the greatest risk for health disparities, the nurse would note that

Cultural differences exist in the ability of patients to communicate with their health

Forcing one's own cultural belief's and practices on another person is an example of

Cultural imposition

What most accurately describes cultural factors that may affect health?

Diabetes and cancer rates differ by cultural/ ethnic groups

Nurses play an important role in reducing health disparities. One important mechanism to do this is to

Engage in activate listening and establish relationships with patients and families

What is the first step in developing cultural competence?

Examine the nurse's own cultural background, values, and beliefs about health and health care

What is leading determinant of a patient's health?

Genetics Health behaviors Social and physical environment

When communicating with a patient who speaks a language that the nurse does not understand, it is important to first attempt to

Use a trained medical interpreter

As part of the nursing process, cultural assessment is best accomplished by

Using a cultural assessment guide as part of the nursing process