final exam ot 1

Which of the following are true related to nursing diagnosis? Select all that apply

- Describes human responses to a health problem - Include descriptors and risk factors - Relates contributing factors or relationships to identified health problem

Which of the following are true about the inter doctory phase of interviewing. select all that apply

-introduce yourself by name in position - I'm serve behaviour and patients self perception

evaluation of nursing quality may be directly done by which of the following? Select all the

-peer review - The Joint Commission

Which nursing action demonstrates the role nurses play in addressing collaborative problems arising from delegated medically prescribed interventions

Recognising that a patient is having an allergic reaction to prescribed medication and holding the next scheduled dose

You are caring for a patient following bilateral measeck to me surgery. The patient refuses to look at her chest and States "I'm hardly even a woman now." What nursing diagnosis would be most applicable to the situation

Disturbed body image

2 nurses are performing a change of shift handoff at the bedside of a patient with the recent abdominal surgery who is receiving a constant infusion of opioid via a patient controlled analgesia(PCA) IV pump. The off going nurse provides a thorough report including the plan of care and the biggest safety risk. What else should the nurses do as part of their handoff?

Double check of high alert infusion reigns

Dinner 6 showing a patient who recently received a prescription for insulin Junction how to perform a subcutaneous injection. The nurse asked a patient to demonstrate back the process of administering the medication.What type of nursing intervention is the nurse practicing?

Educational

When language differences exist between the nurse and the patient, the nurse should do which of the following 1st?

Establish whether a trained interpreter is needed

A nurse's revising a plan of care for a patient with dysphagia difficulty swelling Related to an esophageal mass The patients goal with to eat more than 50% of a blenderized diet But he is reporting 8/10 pain And shortness of breath when eating. Which fees of the nursing process is impacted when the nurse develops an intermediate goal of pain less than 4/10 While eating?

Evaluation

A nurse Is evaluating the medical centers Approach to mobilising secretions in patients with tracheotomies. Which would be the benefit to using evidence based practice select all that apply

Evidence based practice is evaluated based on outcome studies Practitioner knowledge and personal experience are insufficient Provide cost saving quality care

A Nurse is developing Patient goes for a patient following abdominal surgery. Which of the following are appropriate goals? Select all that apply

- Ambulate in the Hall prior to discharge - Demonstrates deep breathing in splinting of incision - Reports pain level less than 4/10 with no movement

The nurses caring for a team of patients during the shift. Which assessment reflects a time lapsed assessment Type of collecting data?

- Check in the patient's blood pressure a month after educating patient on lifestyle change

Which of the following factors may influence sexual function among individuals? select all that apply

- Cognition - Values and beliefs - Illness - Medications

A nurses providing patient education to a 22 Year old male. Which of the following topics would be most appropriate to include? Select all that apply

- Contraceptive methods - Self awareness -Information about STI's

Examples of subculture include which of the following communities? Select all that apply

- Deaf or hearing impaired - Lesbian, gay, bisexual, transgender, Clear/questioning, enter sex - HIV/aids - Truck drivers

A nurses assisting a post operative patient with effective use of the incentive spirometer. The nurse States that using the IS10 times every hour will awake will help prevent atelectasis , enabling the patient to regain her baseline health and return home sooner to be with her children. To gather the patient and nurse developer practice schedule that allows the patient to take a break for visitors in the afternoon. Then the patient verbalises to the nurse which he has learned in demonstrates her skills with the IS. Which patient education practices are evident in this scenario? Select all that apply

- Developing patient rapport - Individualising education to patient - Negotiation of plan of care - Interactive education technique

Which of the following are characteristics of culture? select all that apply

- Learned - Dynamic - Ethnocentric - Relative to context

Nursing care may be influenced by the culture of both the patient and the nurse. Which of the following techniques will assist nurses in performing culturally competent care? Select all that apply

- Minimise ethnocentric tendencies - Knowledge of biocultural variation - Consider patient perspective

Which of the following are elements that improved documentation when using an electronic health record select all that apply

- Nurses are tasked to perform scheduled - Reassessment of pain medication is scheduled depending on administration route - Computerised order entry to directly communicate orders legibly And timely - Access codes to track patient care and compared to establish standards of care

What are important factors in setting nursing priorities? Select all that apply

- Patient condition - Reassessment data - Feedback from the family and health care team

The nearest has admitted a single mother with nausea and vomiting for the last 3 days and upper left Quadrant abdominal pain. Which of the following statements best indicate that the nurse is using the functional health patterns Model of assessment? Select all that apply

- Please describe your appetite over the last week - What kind of help have you had from your family since this started - Have you been able to sleep or rest lately as usual

outcome identification serves which of the following purposes? Select all that apply

- Providing individualised care - Planning care that is realistic and measurable

A nurse is performing patient education related to a new therapeutic regime. Incorporating which of the following factors would be most applicable in promoting adherence? Select all that apply

- Social support and coping - Self-efficacy

Which focuses would be considered priorities by the nurse engaged in active nursing research? Select all that apply

-Evaluating the perceived well being of patients -Identifying ethical frameworks used when questioning participants regarding issues considered confidential -Identifying means by which side effects associated with antipsychotic Medication therapy can be minimised -Evaluating the effectiveness of a newly designed tool to assess cognitive impairment in nonverbal patients

A nurse is conducting an admission Assessment on a confused patient brought in by his son Which of the following would be included in primary sources for information select all that apply

-Physical assessments - Patients report of physical symptoms

Physical factors that may affect sexuality include which of the following? Select all that apply

-dyspareunia - ejaculatory dysfunction

Good nurses establishing a plan of care for a patient with dyspnea and pneumonia. Which of the following is an appropriate addition to the plan of care for this patient?s

-impaired mobility related to Dyspnea as evidence by shortness of breath with position Change -Patient reports no shortness of breath after ambulating to bathroom by time of discharge - Clinical pathway for pneumonia including anticipated length of stay

The nurses caring for group of patients on the medical/surgical unit. Which assessment findings by the nurse reflects objective data?

A 2" head laceration

A nurse is conducting a focus assessment of a hospitalised patient who is a fall risk. Which of the following would be the most appropriate?

Are you more unsteady on your feet when you are out of bed today ?

The nurses caring for a patient who had abdominal surgery yesterday. Which nursing action reflects initial assessment step of the nursing process?

Listening to breath sounds at the beginning of the shift

The nurses developing nursing diagnosis for a patient with chronic pain related to bone cancer. Which of the following Would be most correct?

Activity intolerance related to chronic pain as evidence by patient stating pain 10/10 with movement

A nurse's formulating a nursing diagnosis for hospitalised patients with acute mental status changes and urinary tract infection. Which nursing diagnosis are appropriate select all that apply

Acute confusion related to you too I as evidence by patients statement that she is at home

Which description of value based purchasing is most accurate

Ad justing reimbursement based on measurement of processes, outcomes, and patient satisfaction

Nursing research includes systematic inquiry into which of the following

All of the above ( Clinical practice, Education, Administration)

A young adult diagnosed with syphilis tells the nurse, I don't want my new boyfriend to know about this period what responses by the nurse best presents the information to needs to convey in a caring professional manner?

All of your sexual partners past and present need to be notified so that antibiotic therapy can be prescribed to treat the infection and prevent reinfection

The nurses plenty to teach the patient, who has 3 chronic illnesses, the importance of influenza immunization. How will the next evaluate the patient's understanding?

Ask the patient to explain the information back to the nurse

A teenage girl scene for annual physical remarks that she is so ugly. What should the nurse do 1st?

Ask the patient to explain why she feels this way

Which intervention demonstrates the nurses fulfilment of a standard of nursing practice

Assessing a newly admitted patient for potential fall risks

A nurse fails to observe and document a patient change in neurologic status ultimately resulting in the patient's death from a stroke which type of malpractice is most relevant

Breach of duty

The nurse is teaching a patient who has a new diagnosis of adult onset diabetes the facts regarding sick days. After 10 minutes of explanation, the nurse ask the patient to answer some questions to ensure understanding. Which learning domain is being used by the nurse?

Cognitive

Your nurse manager informs you he is using the tool asking why 5 times to investigate medication error in which you were involved what was the nurse manager doing

Conducting root calls analysis's

A patient is scheduled to receive metoprolol For blood pressure control at 9:00 p.m. the order reads for SBP greater than 90, 25mg PO daily. prior to admission the nurse rechecks the blood pressure in finds it to be 90/50 With the heart rate of 68. This is an example of using what type of nursing skill?

Critical thinking

The nurse tells a patient that pain medication is prescribed to be administered every 4 hours when needed and promises the patient that a pain assessment will be performed. The nurse assesses the patient's level of pain and the need for pain relief every hour. Which ethical responsibility to the patient is the nurse practicing

Fidelity

Nurses caring for a patient who came from a country in Asia. The patient is used to washing the perineal area with water after each toilet use and is requesting a water bottle. What is the most appropriate nursing action?

Give the patient of Perineal cleansing bottle

A nursing a teenage girl at the annual visit. In her assessment what the girl's sexual activity which question would be the most appropriate to ask 1st?

Have you begun menstruating

Which patient statement describes the most self destructive behavior?

I only smoke cigarettes when I'm with my friends

Which statement made by a nursing student using websites as information resources Damage trees and understanding of appropriate site selection criteria

I was familiar with both the authors since they have authored a textbook I am currently using

A nurse's admitting a patient with congestive heart failure. Which of the following describe appropriate aspects of assessment?

Identify activities that Exacerbate symptoms

An antibiotic is ordered that the patient has had an allergic reaction to in the past which would be inappropriate nursing action as determined by the professional nursing role select all that apply

Identify that the antibiotic is inappropriate Document the allergy and call the physician

A male nurses the scientific care for a 40 year old woman who believes that only her husband can see parts of her body that are usually covered with clothing. What is the most appropriate action for the nurses take when the patient ask for a female nurse?

Inform the patient that he will find another nurse to care for her needs

During shift handoff a patient is described as being non compliant to her diabetes management. Her past medical history includes bipolar disorder, depression, chronic back pain, and renal failure with haemodialysis. Upon talking to the patient the nurse learns that the patient is from the Philippines, has no family locally, and has high levels of chronic pain. Which statements by the nurses the most appropriate

Is seems that she has a lot of issues that may be related to her psychological state may be impacting her ability to be adherent

And nurses working in an organisation that prescribes and supports plan B as a form of contraception. And mls in the nurse's role and moral values the nurse should consider which of the following select all that apply

Is the nurse affirming the patient's desires Is the nurse upholding the ethics of the professional What are the nurses beliefs biases related to this What are the consequences in alternatives of giving or not giving this medication

A nurses is caring for a patient with leg ulcers. The nurse assesses that these are related to venous stasis, but when asked the patient reports that there is "someone shooting lasers through the floor" in the apartment. In order to progress with wound treatment what must the nurse understand about resolving value conflict

It is necessary to establish common ground about therapy goals Further exploration of the patient's belief system may need to be identified beliefs related to care The nurse minutes to answer patient questions related to care The nurse may need to examine personal values related to mental health and care

A nurse in the transplant ICU is caring for a teenager following a liver transplant as the result of a Tylenol overdose the patient also superceded another ICU patient who subsequently died without the transplant the patient does not want treatment in States I just want to die the nurse questions the principles of health care ethics in this case which principle would be most in question

Justice

a 35 year old patient who is married is apprehensive about her scheduled masectomy procedure. After assessing the patient's knowledge about the procedure, the nurse manages the patients fear by explaining the procedure and plans for the patient to see the oncology nurse educator. Which fundamental criterion of the self appraisal Did the nurse helped the patient reflect?

Meaning

A group of nurses are discussing a patient case in the elevator when a group of people enter the elevator. What aspect of HIPPA Is most Directly in violation?

Minimum disclosure of protected health information

The nurses caring for a patient after gastric bypass surgery. The goal is for the patient to be able to feed herself appropriately. The patient correctly States, "I should only drink 30 CC of juice hour." The peace and struggles to demonstrate measuring and monitoring of intake frequency, as she is having frequent vomiting. How would the nurse evaluate the attainnment of this goal?

Modification of plan of care needed

The nurses caring for a patient who had a surgical repair to a fractured tibia. the nurse uses a gait belt while ambulating the patient for the 1st time. Which ethical responsibility is the nurse promoting

Nonmaleficence

Which statement about patient safety is correct

Nurses playing important role in keeping a patient safe

A nurse's developing outcome criteria for patient following Abdominal surgery. Which of the following is most appropriate?

Patient ambulate safely Hall twice on postop Day 2

And nurses caring for 4 patients for the 1st time. When patient is admitted with respiratory distress reports no shortness of breath, SpO2 is 95% on 2LNC and RR is 18. The other patient is admitted for laparoscopic Prostatectomy, Complaints of 6/10 pain and has new on site of hematuria In the foley catheter. The 3rd is an IV drug user with abscess and pain 3/10 and wants to go outside to smoke. The final patient is an elderly confused patient admitted with a urinary tract infection and is determined to be a fall risk. Which patient should be the nurses priority?

Patient number 2 admitted for laparascopic Prostatectomy

And erses reviewing a care plan for a patient diagnosed with chronic obstructive pulmonary disease COP D who's experiencing a moderate shortness of breath. Which planned outcome is correctly written for this patient?

Patient will ambulate safely with one purse in assist once during the day shift

A patient has just received a new cancer diagnosis after being hospitalised for fatigue and anemia. The nurse has information about how to improve red blood cell counts through appropriate Nutrition. What is the most important thing that the nurse should know prior to conducting this education?

Patients emotional state

A patient with the pregnancy of 9 weeks is discussing your desire for an elective abortion with the nurse. According to the PLISSIT model of counselling, Which would be the nurses best response after giving the patient permission to discuss abortion?

People choose contraceptive methods that are appropriate further situation

A nurse receives a patient at hand off who is experiencing acute changes in neurologic status. Which nursing action should be done 1st?

Perform a neurological assessment

Which of the following are ethical and legal issues related to the research process that are evaluated by IRBS? Select all the apply

Privacy indignity Balance between benefits and risk Protection from mental and physical suffering

A nurse's developing medication safety protocols for the hospital and is looking at the Appropriate delivery of crushed medication via gastric tubes. This is an example of what type of evaluation?

Process evaluation

A nurses caring for a patient with anorexia. Which of the following would be an example of interpersonal nursing Interventions?

Provide opportunity to examine values

What nursing action best Demonstrates an activity focused on the safety goal of reducing the risk of healthcare associated infections

Providing an in service on the appropriate technique to be used when providing indwelling catheter care

A nurses teaching a post operative patient how to change the leg bag prior to discharge. The skill demonstration by the patient displays which type of learning

Psychomotor

The nearest Costa provider regarding a patience increased output from a surgical Jackson-Pratt drain. She Relays the following information: The patient has had 600 ML of serosanguineous drainage from his JP drain over the last 2 hours; The previous 8 hours shift had a total of 160 ML. Here's post up day number one for prostatectomy. He has had no increase in pain but is now hypotensive with a bp of 100 / 64 and a heart rate of 98. I think he has a urine leak. What is missing from this SBAR communication?

Recommendation

A nurse is conducting a research study of post operative Pain medications. What should be done 1st?

Review the literature

The nurses formulating a nursing diagnosis for several patients. Which nursing diagnosis is correctly written?

Risk for 4 related to newly diagnosed high blood pressure and a prescription for an antihypertensive medication

Which of the following statements is an accurate nursing diagnosis?

Risk for ineffective breastfeeding related to poor infant latch

Shared culture is most accurately seen among people with which of the same features?

Rituals

Self perception or personal identity is how a person explains behaviour based on self observation. Which of the following are dimensions of self perception?

Self knowledge, self expectation, social self, and self evaluation

What is the initial action inertial take when preparing a public presentation to discuss variations in gender identification at a community youth centre?

Self reflect to identify any personal biases that exist on the subject of gender variation

A patient with esophageal cancer is no longer able to consume foods by mouth and is now via fed a gastric feeding tube the patient is withdrawn in States may family used to have big dinners with friends family lots of laughter and loud conversations which of the patient's values are apparent and best describes behaviour

Socialization

In conducting an assessment of a patient with gastrointestinal bleeding the nurse uses which of the following pieces of subjective data ? select all that apply.

Spouses statement of symptoms

The unlicensed assistive personnel comes out of the patient's Room and reports to the nurse that the patient is really breathing hard and can hardly say an understandable word. Which instruction should the nurse give to the unlicensed assistive personnel?

Stand by and help the nurse at the patient's bedside

A patient is admitted with renal failure and oliguria. Which Should be done 1st in formulating a nursing diagnosis?

Synthesise data including urine output, colour of urine, And potassium levels

The nearest developed secure plan for a patient who was admitted for uncontrolled hypertension. Prior to calling the Practitioner for medication, the nurse checked the patient's blood pressure level using a manual machine. Which nursing skill is the nurse using for the assessment?

Technical

You have been asked to participate in a committee rating a policy for the care of a patient with an indwelling catheter what is most important to include

The nationally Recognised catheter associated urinary tract infection prevention bundle

A nurse's brother is admitted to the hospital. The nurse opens and reads the brothers laboratory report in the electronic health record, per the mother's request, without the patient's permission. What will most likely happen to the nurse?

The nurse will be retrained or terminated

A novice nurse has made what is considered a human error while performing as medication nurse on the busy long term care nursing unit. What intervention implemented by the units nurse manager would be most appropriate in this situation to help prevent similar errors in the future

The nurses asked to identify and discuss the factors that contributed to The making of the error

As a patient is admitted to the ICU, the nurse documents that the skin is intact. The patient is in the unit for nearly a month, and a chart audit discovers that no wound care which started in the wound care nurse consult was not done until the patient was transferred to a medical/surgical unit . At this time, the patient's skin is documented as having a stage 2 pressure ulcer on her Coccyx. What does this lack of documentation indicate?

The nursing role of care planning is not apparent

The nurses writing a planned outcome on the computer for a patient who is diagnosed with chronic kidney disease and is on renal diet. What is the most important aspect in developing this step of the nursing process ?

The patient's feelings regarding a renal diet

Which statement is true about Latent errors

They are errors that are due to system issues

Bundling findings to improve Care is now a nursing standard in the care of patients with heart failure and husband shown to reduce readmission rates. This is one example of which of the following research aspects?

Translation of research to practice

The nurse who hasn't assignment of 5 patients for the shift, follows a routine of getting bedside report from the outgoing nurse, assessing the patients, and providing immediate care as needed. What is the best practice for documenting?

While in the patient's Room performing each procedure

A-day one post operative patient has the following abnormal assessment findings pain 7/10, diminished lung sounds, hypoactive bowel sounds, and a saturated bloody abdominal dressing and bedsheets. Which would be the nursing priority?

Wound care

1. According to Patricia Benner's From Novice to Expert, there five distinct levels of proficiency. Micah is a nurse with years of experience who is able to analyze his patient's heart failure conceptually related to renal failure and anemia that are present rather than as separate issues. Which level most appropriately describes proficiency?

advanced beginner

Marcy is aware that nursing responsibilities are related to standards of professional performance. which are included in these standards?

collaboration performance appraisal quality of practice

A nurse sees a patient in the cardiology office for coronary artery disease and congestive heart failure. It has been recommended that the patient eat a diet low in sodium, but he confesses that he has not consistently modified his diet, though he does understand that sodium intake increases fluid retention. Which of the following nursing diagnosis is most appropriate for this patient?

ineffective therapeutic regime management

Nursing student is asking the preceptor the importance of formulating a nursing diagnosis. What statement by the preceptor is the best answer to the graduate nurses question?

it keeps a patient safe by focusing attention on the patient's actual or potential problems

A nurse's charting the application of medication and dressing change on the patient's pressure ulcer. which purpose of health care record keeping requires the nurse to provide a meticulous recording using the guidelines of the centers for medicare and medicaid?

reimbursement

The nurse is discussing home care of a patient with a below the knee amputation month ago. She's expects a self care deficit because the patient reported that he sits in his chair and watches television all day and does not shower or eat regularly. What intervention would be most appropriate to address the altered self concept?

self evaluation

A patient reports frustration that she has been unable to sleep while in the hospital and that she's exhausted the nurse also notes that the patient has an unreliable social support network has put confidence in her ability to care for herself after discharge and is at risk for a fall which of these issues would take priority according to Manslow hierarchy of human needs

sleep

A home care nurse is caring for a quadriplegic client who needs regular position changes and back massages. A visitor identifying as a family friend inquires about helping the family. What should be the nurse's response be?

talk to the family directly

a nurse is found to have performed procedures outside her scope of practice. identify which element is true related to nursing scope of practice

the scope of practice is defined by each statrs nurse practice act.